Concepts of Healthcare Systems
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| True or False: The cost of health care in the US is astronomical? | True
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| What happens to small rural hospitals who at times can't bear to stay open? | Bought out by larger corporations
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| What is a Health Care delivery system? | A means to provide services to meet the health needs of individuals in their country
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| Explain both profit & non-profit healthcare | Produce & provide services, are incorporated, have a board of directors and/or owners, operate to make a profit and make investments
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| What are the five keys to providing health care? | Heath care, cost, who pays for service, how it's paid & where payment goes, current & future trends & challenges
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| What does the federal law require with regards to seeking medical care? | Anyone seeking medical care in an emergency room must be seen regardless of ability to pay
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| Who has the most affordable insurance? | Employer
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| What is a high risk pool? | Those with serious medical conditions that prevent them from obtaining standard insurance (very expensive insurance)
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| What is DRG? | Diagnosis Relate Group - used to reduce the cost of health care, diagnosis related group codes, cost reimbursement plan that classifies patients according to age, diagnosis, and if applicable the surgical procedure, & determines pymnt for that procedure
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| What is a Health Department? | Focuses on general health of the citizens; services: food handling & licensing, vaccination program, free STD & AIDS testing, etc
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| What does the Social Security Admin do? | Pays retirement, disability, & survivor benefits to eligible workers and families
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| What is Medicare? | Medical insurance program designed for persons over 65 yr old or persons with disabilities or chronic health conditions
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| What is Medicaid? | Medical insurance programs for eligible low-income, medically or physically = dosable clients
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| What is a PPO? | Preferred Provider Org. - Managed health care plan that combines HMO & traditional insurances
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| What is HMO? | Health Maintenance Org. - Limits the consumers choices to specific doctors & hospitals, based on prepaid, managed plans
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| What is modular nursing? | Approach that focuses on efficiency by assigning a team of nurses to limited areas or specialty
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| What is team nursing? | Total client care to a group of clients
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| What is functional (task) nursing? | The needs of a group of clients are broken down into a task
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| What is the VA? | Dept. of Veterans Affairs - Enrolled US Veterans who qualify for a broad range of programs & services at a VA provider
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| What is case management? | Collaborative process of meeting client needs
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| What is client acuity? | Refers to the level of care needed for a particular client
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| What is critical paths? | Standard patters of client care healthcare providers follow that documents the essential steps in the diagnosis & treatment of a clients condition
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| What is a deductible? | The amount the client pays before insurance begins to pay for treatment. Once deductible is met, insurance covers 80% and client pays the remaining 20%, most insurances have an annual cap
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| What is managed care? | One of the most common types of healthcare systems that uses organizational strategies to contain health care cost
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| What is PCP? (Not the drug!) | Primary Care Provider - a physician who participates in a managed care program
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| What does IHS stand for? | Indian Health Services - Specify funds for national Indian Health - American Indian tribes & Alaska Native Indians
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| Who has fixed fee guidelines for payments, and if the client requires more care does not reimburse the physician for extra cost? | Government Health Programs
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| What is indemnity insurance? | Type of insurance coverage with few controls regarding accessing care - insured person pays the premiums & an annual deductible
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| Who considers preventative care a luxury? | Those who can not afford health insurance
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| If you have service managed care, what does that mean? | It defines which services are covered by the insurance company
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| If your physician does not renew his contract with a managed care group, can you follow him where he moves to? | No
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| What is cost control? | Managed care pays the physicians a set fee to care for a group of clients & limits the services the physicians can offer
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| What is practice partners? | New & innovative way where an RN & LPN/AUA agree to work together w/the same schedule & same group of patients
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| What is evidence-based nursing practice? | Nursing practices & policies are based on scientific studies that have proven positive outcomes
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| What does pay for performance do? | Aligns reimbursement to the provider for client outcomes (if hospital has better than expected outcomes, it gets additional payments)
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| Why should nurses be role models for healthy living? | Recognize that patients often look at what nurses do, rather than what they say
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| The nurse is talking to patient who is over 65 about resources available to assist with cost of health care, what program should she recommend? | Medicare
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| A patient is being discharged 3 days after surgery because of influence of DRG. What should the nurse performing discharge teaching be most concerned about? | Continuity of care
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| The home health nurse is coordinating delivery of health care svcs to an older adult. The nurse considers the fact that what most affects the older adult population is that older adults: | Tend to fall, requiring expensive hospital services
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| What is the major factor that prevents a major overhaul of the health care delivery system in US? | Diagnosis & treatment
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| What is a patient classification system designed to do? | Establish that quality standards have been met
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| What is the greatest challenge to the financing of health care in the US? | Older Adults
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| What word best describes a nurse who is functioning as a patients advocate? | Protector
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| What does preauthorization mean? | Third-part payer has to approve the surgery & facility will be reimbursed for cost
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| What is integrated health care system? | Provides care across various health care settings at all care levels, such as primary & secondary
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| What is association based isurance? | Insurance provided through a trade or professional org., or through an affiliation with religious or community group
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