Question 1

Diagnosis-related groups (DRGs) have attempted to reduce health care costs by decreasing:

Accepted Answer

Hospitals face a strong financial incentive from the DRG reimbursement system to reduce the client's length of stay and minimize procedures performed. If hospital costs exceed the DRG payment for a client's treatment, the hospital incurs a loss, but if costs are less than the DRG amount, the hospital makes a profit.

Question 2

A client is admitted with chest pain. A series of diagnostic tests are ordered, and the client undergoes coronary artery bypass grafting. The cost of care for this client is increased because of a four-pack-per-day smoking history that resulted in extension of the client's intensive care unit (ICU) stay by 3 days because of respiratory problems. The case manager realizes that under the terms of the diagnosis-related group (DRG) payment system for this diagnosis:

Accepted Answer

Since 1983, if hospital costs exceed the DRG payment for a client's treatment, the hospital incurs a loss, but if costs are less than the DRG amount, the hospital makes a profit. Hospitals face strong financial incentives to reduce the client's length of stay and minimize procedures performed.

Question 3

The precise classification of clients according to the highest diagnosis-related group (DRG) has created a new role for nurses, known as a _____ nurse.

Accepted Answer

Hospital-based utilization review nurses review medical records to determine the most appropriate DRG for clients. Financial gains can be made through careful diagnosis of clients according to their highest potential DRG classification.

Question 4

Lack of insurance, uninsured populations, and uncompensated care are covered by charging more to those who can pay. This practice is referred to as:

Accepted Answer

Cost shifting occurs when providers increase their charges against households and public and private insurers who pay for their own care while making some contribution to the care of the uninsured population.

Question 5

In February 2010, Congress passed legislation to support universal health care for all Americans. At a local health fair, an individual asks about the difference between universal health care and a single payer system. The nurse explains the difference is that:

Accepted Answer

Universal health has one payer (usually the government) and provides health care for all citizens.

Question 6

A patient wants to reduce health care costs by being a model for making wise decisions that both promote health and reduce cost. Which statement by the patient would indicate a need for further teaching?

Accepted Answer

Ways to reduce health care costs as a consumer include choosing generic drugs whenever possible.

Question 7

A patient is eligible to change health care providers and insurance and asks, "I am interested in health promotion activities; I walk, swim, and eat healthy. Which health insurance plan would support these activities rather than just pay for services when I am sick"? Which, if any, health insurance plan would best meet the needs of this patient?

Accepted Answer

HMOs encourage preventive care.

Question 8

A young mother has detected a lump in her breast, and because she lives at the poverty level, she is covered under Medicaid. This individual:

Accepted Answer

Even with improved access as compared with the uninsured, Medicaid recipients are not as likely to obtain needed health services. The poor are more likely to lack a usual source of care, are less likely to use preventive services, and are more likely to be hospitalized for avoidable conditions than are those who are not poor.

Question 9

A patient is upset because her health insurance plan refused to pay for a mammogram and services by a women's health specialist because the primary care physician did not order the referral or the mammogram. Which type of insurance plan adheres to this type of payment system?

Accepted Answer

HMOs require patients to select a primary care physician approved by the HMO who then must refer or order any test/diagnostic procedures before payment is approved or preapproval must be sought.

Question 10

An elderly person, age 80, is finding it difficult to live alone and the family is considering long-term care. The elderly person is reasonably healthy, with only normal aging declines, and maintains a healthy appetite. All medications are administered orally and require only minimal assistance. She is financially secure with an income based on retirement from both the military and factory from her deceased husband and herself. The family contacts long-term care and is told that, based on this patient's information:

Accepted Answer

Medicare does cover home health care.

Question 11

Health care is one of the major stories in newspaper and television and a group of nurses are interested in how the economy impacts their nursing practice. The group critiques the relationship between contemporary economic trends and professional nursing practice and finds:

Accepted Answer

Pay for performance, where providers are reimbursed based on the quality of care, gives nurses an opportunity to reduce costs and adopt practices that improve quality of care.

Question 12

In the triad of health care, which would be considered the third-party payer?

Accepted Answer

The third-party payer is an organization other than the client and the supplier (hospital or physician), such as an insurance company, that assumes responsibility for payment of health care charges.

Question 13

A nurse is newly employed by a state-owned hospital that provides health care insurance requiring a deductible paid by the employee with the majority of the premium cost covered by the employer. The insurance provided to the nurse is:

Accepted Answer

Private health insurance is a method for individuals to maintain insurance coverage for health care costs through a contract with a health insurance company that agrees to pay all or a portion of the cost of a set of defined health care services and is typically provided through an individual's employer with a portion of the cost paid by the employer and a portion paid by the employee.

Question 14

A client who is reading a newspaper asks, "This article about health care states that many providers of health care lack effectiveness. What is the difference between effectiveness and efficiency?" The nurse explains that:

Accepted Answer

Efficiency means using the right combination of resources-energy, time, and money-to accomplish a task, and effectiveness means doing the right thing right in health care.

Question 15

When reviewing the literature on the effects of Medicaid on health care for the poor, the nurse researcher found that the poor:

Accepted Answer

The poor are more likely to lack a usual source of care, are less likely to use preventive services, and are more likely to be hospitalized for avoidable conditions than are those who are not poor.

Question 16

A nurse is offered several health care plans as part of employee benefits. Which plan is based on a monthly fee per participant and offers a range of preventive, diagnostic, and treatment services?

Accepted Answer

Capitation is a method of reimbursing providers (usually, primary care providers such as physicians or nurse practitioners) in which the insurance company pays the provider a set amount of money each month to provide a defined set of health care services under this plan. Payment is generally received as a per-member-per-month payment. Defined health care services generally include preventive, diagnostic, and treatment services.

Question 17

Certain groups of individuals are opposed to the Patient Protection and Affordable Care Act (PPACA) based on religious beliefs that prohibit circumcision and blood transfusions. These individuals believe the PPACA is unconstitutional because it:

Accepted Answer

The PPACA is a type of national health insurance program to provide funding for U.S. citizens and legal residents to secure health insurance beyond the current programs such as Medicare and Medicaid.

Question 18

A physician bills the insurance company for a computed tomography (CT) scan, laboratory tests, chest x-ray, and an extended visit and receives revenue for each procedure billed. This type of payment system is a _____ payment system.

Accepted Answer

A retrospective payment system is a method of reimbursing health care providers (such as physicians and hospitals) in which professional services are rendered and charges are billed on the basis of each service provided; this is also known as a fee-for-service payment system.

Question 19

An older adult client was admitted to the hospital with the condition classified as "pneumonia." Reimbursement was based on a predetermined fixed price. This classification system is referred to as:

Accepted Answer

DRGs are used in reimbursement for health care services based on a predetermined fixed price per case or diagnosis in 468 categories. Under DRGs, each Medicare client is assigned to a diagnostic grouping on the basis of his or her primary diagnosis at hospital admission. Medicare limits total payment to the hospital to the amount pre-established for that DRG.

Question 20

A contractual agreement between the insurer and the provider in which covered members are encouraged to use specific health care providers in return for reduced rates is which type of arrangement?

Accepted Answer

A preferred provider organization is an arrangement by which the member pays a premium for a fixed percentage of expense coverage. This method includes a required deductible and a copayment. The member may select a physician but pays less for physicians and facilities on the plan's preferred list.

Quiz 7: Paying for Health Care in America: Rising Costs and Challenges