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

Question 1

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

A) hospital admission rates.
B) length of hospital stay.
C) outpatient services.
D) specialty groups.

Answer 1

length of hospital stay.

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:

A) the cost of caring for this client was $5000 greater than the DRG reimbursement fee, and the hospital will be allowed to collect the additional fees from the insurance company.
B) although the cost of care for this client was greater than the DRG reimbursement amount, the hospital will be reimbursed only at the set fee.
C) the client will be sued to pay back the insurance company for the extra fees incurred because smoking is a modifiable health risk for heart disease.
D) the physician who admitted the client will receive a reduced payment to cover the loss incurred by the hospital.

Answer 2

although the cost of care for this client was greater than the DRG reimbursement amount, the hospital will be reimbursed only at the set fee.

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.

A) case management
B) quality assurance
C) utilization review
D) cost-control

Answer 3

utilization review

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:

A) charity.
B) cost shifting.
C) price sharing.
D) governmental reimbursement.

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:

A) with universal health, one universal payer, usually the government, pays all expenses for health care.
B) single-payer systems offer health care only to eligible persons based on income.
C) single-payer systems rely on insurance companies to pay predetermined fees for services.
D) with universal health, one payer is responsible for all health care costs, providing health care to 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?

A) "I will ask for the brand name drug Tylenol rather than acetaminophen since it works better and I won't be sick as long."
B) "I looked up urinary tract infection prevention on the Internet."
C) "I had my weight, body fat, and blood sugar measured at a local health fair."
D) "My allergies are really bothering me. I spoke to the pharmacist, who recommended an over-the-counter antihistamine."

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?

A) Health Maintenance Organization (HMO).
B) Fee for Service.
C) Preferred Provider Organization (PPO).
D) None, because health insurance plans currently cover only disease management, not 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:

A) is more likely to participate in mammography screening than are individuals covered by private insurance.
B) has designated primary care and a specialist as sources of care.
C) will more likely wait to seek care and will require hospitalization for a mastectomy, which could have been avoided if care had been sought earlier.
D) has decreased access to health care when compared with the uninsured.

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?

A) Fee for Service
B) Health Maintenance Organization (HMO)
C) Preferred Provider Organization (PPO)
D) Point of Service (POS)

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:

A) Medicare will cover the cost of stay since skilled services are required.
B) Medicaid is only for families with dependent children.
C) Medicare will pay for home health services should these additional services meet the needs of the individual.
D) Medicare will pay regardless of household income or financial status for nursing home 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:

A) the implementation of the DRG system led to the nursing shortage since cost of nursing care is not billed.
B) nursing care is focused on technologically advanced acute care rather than preventive, patient-centered care.
C) with pay for performance, nurses have a significant effect on the quality of patient outcomes by reducing errors and providing care based on best practices.
D) economic issues have little or no impact on nursing practice.

Question 12

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

A) Client
B) Health care provider
C) Insurance company
D) Government agency that sets reimbursement rules for services

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:

A) private health insurance.
B) a federal insurances program known as PPACA.
C) state-subsidized Medicaid insurance.
D) single-payer system coverage.

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:

A) effective means performing the correct test or intervention whereas efficiency refers to the wise use of supplies and resources for the desired outcome.
B) effective refers to competence in clinical practice and efficiency describes quick completion of the task.
C) efficiency means wasting and meeting a minimum standard and effectiveness refers to taking all the time needed to exceed expectations.
D) efficiency refers to speed and effectiveness refers to the usefulness of the implementation.

Question 15

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

A) have less access than even the uninsured.
B) receive many unnecessary treatments.
C) lack consistent providers.
D) abuse preventive services.

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?

A) Prospective payment system
B) Retrospective payment system
C) Single-payer system
D) Capitation

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:

A) mandates that all U.S. and legal residents must secure health insurance.
B) replaces current Medicare and Medicaid plans.
C) requires all citizens to participate in offered preventive services.
D) prohibits use of health practices outside of Western medicine.

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.

A) prospective
B) retrospective
C) diagnosis-related group
D) capitated

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:

A) diagnosis-related groups (DRGs).
B) subjective symptom management.
C) acuity classification system.
D) organized managed care.

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?

A) Health maintenance organization
B) Preferred provider organization
C) Fee-for-service arrangement
D) Philanthropic agency

Question 21

Medicare would be responsible for: (select all that apply)

A) a hospital stay following a total knee replacement for a 70-year-old client.
B) nursing home cost for a 67-year-old adult receiving hemodialysis.
C) rehabilitation care costs for a 24-year-old client with a broken femur resulting from a fall at work.
D) prescription cost for a young mother who meets eligibility for Aid to Families with Dependent Children (AFDC).
E) home health services to administer heparin to a 27-year-old truck driver following a thrombus.

Question 22

A 72-year-old client is admitted to have the right kidney removed after a diagnosis of cancer. The surgeon removed the left kidney. Medicare will no longer pay for preventable medical errors known as ____________.

Question 23

A nurse who speaks at a health fair states that current attempts to increase efficiency of health care include: (select all that apply)

A) an increase in acute care, so that specialized care can be provided.
B) the growing use of outpatient services.
C) shifting toward health promotion and prevention.
D) allowing physicians to control health care decision making.
E) the use of technology to educate the public about cost-effective measures.

Question 24

A nurse is very interested in learning more about health care economics and how she can use that knowledge to become a better patient advocate. She comments, "Nurses should not only deliver care one day at a time in one facility but should coordinate patient care as they move from acute care to rehabilitation to home care." This nurse would be a candidate for which nursing role?

A) Disease management program (DMP) for chronic illnesses
B) A hospital-based utilization management nurse who reviews medical records to determine the most appropriate DRG for patients
C) Case management
D) Reviewer for Managed Care Organization

Question 25

The largest single payer of hospital charges in the United States is ___________.

Question 26

The type of insurance that shifts the largest percentage of costs for goods and services to employees and consumers is _____________ insurance.