Question 1

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 referred to as which type of arrangement?

Accepted Answer

Preferred Provider Organization (PPO) plans involve agreements with medical providers to create a network of "preferred" providers. Members are encouraged to use these providers through incentives like lower copays and reduced rates, but they can also see providers outside of the network at a higher cost.

Question 2

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

Retrospective payment systems reimburse healthcare providers after services have been delivered, based on each service provided. This contrasts with prospective payment systems, where the amount to be paid is determined before the service is delivered, often based on a predetermined rate or diagnosis-related group. Capitated payment systems involve a set amount paid per patient regardless of the number of services provided.

Question 3

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

Accepted Answer

Private health insurance often involves a deductible paid by the insured, with the premium mostly covered by the employer, distinguishing it from government-funded programs like Medicaid or single-payer systems.

Question 4

Diagnosis-related groups (DRGs)have attempted to reduce health care costs by decreasing what component of care?

Accepted Answer

DRGs have been implemented to reduce healthcare costs primarily by decreasing the length of hospital stay. They do this by setting predetermined payment amounts for specific diagnoses, incentivizing hospitals to manage patients more efficiently.

Question 5

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 best responses with what statement?

Accepted Answer

Effectiveness relates to doing the right things to achieve the desired health outcomes, such as performing the correct tests or interventions. Efficiency, on the other hand, involves using resources wisely (such as time, supplies, and labor) to achieve those outcomes in a cost-effective manner.

Question 6

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 bases on what premise?

Accepted Answer

The Patient Protection and Affordable Care Act (PPACA) mandates that all U.S. citizens and legal residents must secure health insurance, which is the primary reason certain groups oppose it based on their religious beliefs against practices like circumcision and blood transfusions. They argue this mandate infringes on their religious freedom.

Question 7

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 payment arrangement for health care service providers such as physicians, nurse practitioners, and others. It involves a set amount per patient per unit of time paid in advance to the provider for the delivery of health care services. This system encourages providers to offer comprehensive care within the fixed budget, as the payment is not related to the number of services provided but is a flat monthly fee for each enrolled patient, covering all or most of the patient's care.

Question 8

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

Health Maintenance Organizations (HMOs) focus on preventive care and wellness activities, making them a suitable choice for someone interested in health promotion activities. They often provide programs and incentives for maintaining a healthy lifestyle, which aligns with the patient's interests in walking, swimming, and eating healthy.

Question 9

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

Choice A indicates a need for further teaching because it is based on a misconception that brand name drugs are more effective than their generic counterparts. In reality, generic drugs have the same active ingredients and are just as effective as brand name drugs but are often significantly cheaper. This choice does not promote reducing health care costs.

Question 10

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 based on what fact?

Accepted Answer

With universal health, one payer is responsible for all health care costs, providing health care to all citizens.

Question 11

A young mother has detected a lump in her breast,and because she lives at the poverty level,she is covered under Medicaid.What is the most likely consequence of this woman's situation?

Accepted Answer

Medicaid patients often face barriers to care, including longer wait times for appointments, which can lead to delays in seeking care. This delay can increase the risk of being diagnosed with advanced stages of diseases such as breast cancer.

Question 12

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.When the group critiques the relationship between contemporary economic trends and professional nursing practice,what fact will they discover?

Accepted Answer

The implementation of pay for performance in healthcare means that healthcare providers, including nurses, are rewarded for meeting certain performance measures for quality and efficiency. This incentivizes nurses to focus on reducing errors and providing care based on best practices, directly impacting patient outcomes. This system acknowledges the critical role nurses play in healthcare delivery and quality improvement.

Question 13

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 that the client's past history and present care needs will have what affect on reimbursement?

Accepted Answer

Under the DRG payment system, hospitals are reimbursed a fixed fee for a given diagnosis, regardless of the actual cost of care. This means that if the cost of care exceeds the DRG reimbursement amount, the hospital absorbs the extra cost without additional reimbursement from the insurance company.

Question 14

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

Accepted Answer

The third-party payer in the triad of health care is the insurance company, which pays for the health care services on behalf of the client.

Question 15

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 given what information,based on this patient's situation?

Accepted Answer

Medicare can cover home health services if they meet the individual's needs, especially for someone who is reasonably healthy but requires minimal assistance. Medicare does not cover long-term nursing home care costs based solely on financial status or household income, and it typically does not cover long-term stays in nursing homes unless skilled services are needed for a limited time. Medicaid, not Medicare, can help cover long-term care costs for eligible individuals, and it is not limited to families with dependent children.

Question 16

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

Health Maintenance Organizations (HMOs) typically require a referral from a primary care physician before they will cover services by specialists or specific tests like mammograms. This is part of their managed care system, designed to control costs by ensuring that such services are medically necessary.

Question 17

An older adult client was admitted to the hospital with the condition classified as "pneumonia." Reimbursement for care was based on a predetermined fixed price.What is this classification system referred to as?

Accepted Answer

Diagnosis-related groups (DRGs) are a classification system that groups patients based on their primary and secondary diagnoses, procedures, age, sex, and discharge status. This system is used to determine hospital reimbursement for each case in a fixed-price manner, based on the assumption that patients within the same group will use similar hospital resources.

Question 18

When reviewing the literature on the effects of Medicaid on health care for the poor,what common problem would the nurse researcher find?

Accepted Answer

A common problem found in the literature regarding the effects of Medicaid on health care for the poor is a lack of consistent providers. This inconsistency can lead to fragmented care and difficulties in managing chronic conditions effectively.

Question 19

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

The answer of The precise classification of clients according to...

Question 20

Lack of insurance,uninsured populations,and uncompensated care are covered by charging more to those who can pay.What term is used to refer to this practice?

Accepted Answer

Cost shifting is the practice where healthcare providers charge more to insured or paying patients to compensate for the care provided to uninsured or underinsured patients.

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