NUR 212 Exam 2

Health Policy, Healthcare Systems, Advocacy, Legal issues Ethics, Accountability

Medicare

• Elderly (65+)

• Disabilities

  • ESRD

  • ALS

• Federal

Medicaid

• Low-income

• CHIP

  • Infant/Children

• Dual-coverage

• Federal and State

• Child & Maternal Health

  • Pregnancy, labor, delivery, & 60 days postpartum

  • Children enrolled automatically

Medicare Part A

• Hospital Insurance

• Requirements

  • Payment into Medicare tax

  • Copay or deductibles

• Under certain conditions, may cover skilled nursing facility, hospice and home health care following a 3-day hospital stay

Medicare Part B

• Medical Insurance

  • Physicians/PCP

  • Outpatient care

  • Home health care

  • Durable medical equipment (DME)

• Premiums

• Deductible

• Copayment (20%)

Medicare Part C

• Medicare Advantage

• Private Insurance Companies

• Requires Parts A & B

• Additional Benefits

  • Prescription drugs

  • Hearing, vision & dental

  • Health & wellness programs

• Restrictions

  • Locked in network

  • Strict application times

  • Locked in plan

Medicare Part D

• Drug Coverage

• Deductible

• Premiums vary

• Restrictions

  • Part A and/or B

  • Medication limits

  • Formulary drugs covered

What’s HCAHPS?

A 21-item survey instrument and data collection methodology for measuring patients’ perceptions of their hospital experience.

Who can complete a HCAHPS survey?

Recently discharged patients

Utilization Review

Use by insurance companies to assess the need for medical care and to assure that payment will be provided for the care. Typically includes:

• Precertification or preauthorization for elective treatments

• Concurrent review

• Retrospective review for emergency cases (If necessary)

Types of private insurance plans.

• HMO

• PPO

• POS

• CDHP

Individual Private Insurance

• To be insured, members pay monthly premiums either by themselves or in combination with employer payments. These plans are called third-party payers because the insurance company pays all or most of the cost of care.

• Members can choose their own health care providers and services desired.

Majority of private insurance plans are offered through…

Employer or professional organizations

Health Maintenance Organization (HMO)

• A network of providers funded by premiums

• Limited to network

• Members select a primary care provider (PCP)

  • Gate-Keeper

• Pros & Cons

  • Very restrictive

  • Members have very little choice

  • Greater range of benefits for a lower cost

Health care financing and delivery program with a group of providers, such as physicians and hospitals, who contract to give services on an FFS basis. This provides financial incentives to consumers to use a select group of preferred providers and pay less for services. Insurance companies usually promise them a certain volume of patients and prompt payment in exchange for fee discounts.

Preferred provider organization (PPO)

Preferred Provider Organization (PPO)

• Fee-for-service (FFS) organization

  • Incentives to use in-network providers

• Large network of providers

• No PCP/Gate-Keeper

• Pros & Cons

  • Out-of-network care is expensive

  • More choices of health care provider

Point of Service (POS)

• HMO/PPO

• Determined at the time of service

• Limited network

• PCP/gate-keeper

• Pros & Cons

  • Lower costs in-network

  • Out-of-network is expensive (higher premium and copayment)

  • Flexibility and freedom of choice

Consumer-Driven Health Care Plan (CDHP)

• Employer-sponsored coverage

  • Private insurance

  • Health Saving Account (HSA) or Health Reimbursement Account (HRA)

• High rate of insurance

• Deductible are high and taken from salary

• Amounts add to Health Saving Account can be determined by employee or employer

• Most common

Vulnerable Populations

• Prisoners

• Substance Abuse Addicts

• Elderly

• Children

• Minorities

• LBGTQIA Community

• The Unhoused

Three Major Budget Types

• Personnel

• Operating

• Capital

Capital Budget

• Major investment

• Plan for the purchase of buildings or major equipment, which include equipment that has a long life (usually greater than 5 to 7 years), is not used in daily operations, and is more expensive than operating supplies

• $5,000 or more

Short-term component of the capital budget includes equipment purchases within the annual budget cycle, such as…

• Call-light

• Hospital beds

• Medication carts

Operating budget

Reflects expenses that change in response to the volume of service, such as:

• Cost of electricity

• Repairs and maintenance

• Supplies

Personnel budget

• Largest of the budgets expenditures because healthcare is labor intensive

• Includes actual worked time (productive time or salary expense) and time that the organization pays the employee for working (nonproductive or benefit time)

• As patient-days or volume decreases, managers must decrease personnel costs in relation to the decrease in volume. Must also be aware of staffing mix and patient acuity

What does non-productive time include?

• Cost of benefits

• New employee orientation

• Employee turnover

• Sick and holiday time

• Education time

Four Common Budgeting Methods

• Incremental Budgeting

• Zero-based

• Flexible

• Performance

Zero-Based Budgeting

• Must re-justify their program or needs every budgeting cycle

• Does not automatically assume that because a program has been funded in the past, it should continue to be funded

• Decision package to set funding priorities

• Force managers to set priorities and to use resources efficiently

• Complex and time consuming

• Information from peers and subordinates is needed to analyze adequately and prioritize the activities of each unit.

Key components of decision packages in zero-based budgeting

1. Listing of all current and proposed objectives or activities in the department

2. Alternative plans for carrying out these activities

3. Costs for each alternative

4. Advantages and disadvantages of continuing or discontinuing an activity

Performance Budgeting

• Emphasizes outcomes and results instead of activities or outputs

• Manager would budget as needed to achieve specific outcomes and would evaluate budgetary success accordingly

Flexible Budgets

• Budgets that flex up and down over the year depending on volume

• Automatically calculates what the expenses should be, given the volume that is occurring

• Works well in many health care organizations because of changing census and manpower needs that are difficult to predict despite forecasting tools.

Incremental Budgeting (Flat-Percentage Increase Method)

• Multiplying current-year expenses by a certain figure, usually the inflation rate or consumer price index, the budget for the coming year may be projected

• Simple, quick, and requires little budgeting expertise

• No motivation to contain costs and no need to prioritize programs and services

Accountable Care Organizations

Groups of providers and suppliers of service who work together to better coordinate care for Medicare patients (does not include Medicare Advantage) across care settings

Acuity index

• Weighted statistical measurement that refers to severity of illness of patients for a given time.

• Patients are classified according to acuity of illness, usually in one of four categories.

• Determined by taking a total of acuities and then dividing by the number of patients.

Affordable Care Act

Officially known as the Patient Protection and Affordable Care Act, this act passed in March 2010 to provide more Americans access to affordable health insurance

Assets

Financial resources that a healthcare organization receives, such as accounts receivable

Baseline data

Historical information on dollars spent, acuity level, patient census, resources needed, hours of care, and so forth. This information is used as the basis for projecting future needs.

Break-even point

Point at which revenue covers costs

Bundled payment

Healthcare providers who are treating a patient for the same or related conditions are paid an overall sum for taking care of that condition rather than being paid for each individual treatment, test, or procedure. In doing so, providers are rewarded for coordinating care, preventing complications and errors, and reducing unnecessary or duplicative tests and treatments

Capitation

• Providers receive a fixed monthly payment regardless of services used by that patient during the month

• If the cost to provide care to someone is less than the capitated amount, the provider profits

• If the cost is greater than the capitated amount, the provider suffers a loss

Case mix

Type of patients served by an institution. A hospital’s _____ is usually defined in such patient-related variables as:

• Type of insurance

• Acuity levels

• Diagnosis

• Personal characteristics

• Patterns of treatment.

Cash flow

Rate at which dollars are received and dispersed

Controllable costs

• Costs that can be controlled or that vary.

• Example

  • Number of personnel employed

  • The level of skill required

  • Wage levels

  • Quality of materials.

Cost-benefit ratio

• Numerical relationship between the value of an activity or procedure in terms of benefits and the value of the activity’s or procedure’s cost.

• Expressed as a fraction.

Cost center

Smallest functional unit for which cost control and accountability can be assigned.

A nursing unit is usually considered one, but there may be others within a unit (orthopedics is one, but often, the cast room is considered a separate center within orthopedics).

Diagnosis-Related Groups (DRGs)

• Rate-setting PPS used by Medicare to determine payment rates for an inpatient hospital stay based on admission diagnosis.

• Each represents a case type for which Medicare provides a flat dollar amount of reimbursement. This set rate may be higher or lower than the cost of treating the patient in a particular hospital.

Direct costs

• Costs that can be attributed to a specific source, such as medications and treatments

• Clearly identifiable with goods or service

Fee-for-service (FFS) system

Reimbursement system where insurance companies reimburse health care providers a billed amount for services after the services are delivered

Fixed budget

Style of budgeting that is based on a fixed, annual level of volume, such as number of patient-days or tests performed, to arrive at an annual budget total. These totals are then divided by 12 to arrive at the monthly average. The budget does not make provisions for monthly or seasonal variations.

Fixed cost

Costs that do not vary according to volume (ex. loan payments)

For-profit organization

Organization in which the providers of funds have an ownership interest in the organization. These providers own stocks in the organization and earn dividends based on what is left when the cost of goods and of carrying on the business is subtracted from the amount of money taken in.

Full costs

Total of all direct and indirect costs

Full-time equivalent (FTE)

Number of hours of work for which a full-time employee is scheduled for a weekly period.

Health Maintenance Organization definition

Prepaid organization that provided health care to voluntarily enrolled members in return for a preset amount of money on a per-person, per-month basis; often referred to as a managed care organization

Hours per patient-day (HPPD)

• Hours of nursing care provided per patient per day by various levels of nursing personnel.

• Determined by dividing total production hours by the number of patients.

Indirect costs

• Costs that cannot be directly attributed to a specific area. These are hidden costs and are usually spread among different departments.

• Housekeeping services are an example

International Classification of Disease (ICD)

Coding used to report the severity and treatment of patient diseases, illnesses, and injuries to determine appropriate reimbursement; currently in its 10th revision

Managed care

A variety of health care plans designed to contain the cost of health care services delivered to members while maintaining the quality of care

Noncontrollable costs

• Indirect expenses that cannot usually be controlled or varied.

• Examples

  • Rent

  • Lighting

  • Depreciation of equipment.

Non-for-profit organization

This type of organization is financed by funds that come from several sources, but the providers of these funds do not have an ownership interest. Profits generated are frequently funneled back into the organization for expansion or capital acquisition.

Operating expenses

Daily costs required to maintain a hospital or health care institution

Patient classification system

Method of classifying patients. Different criteria are used for different systems. In nursing, patients are usually classified according to acuity of illness

Pay for performance (also known as P4P) programs

Incentives are paid to providers to achieve a targeted threshold of clinical performance, typically a process or outcome measure associated with a specified patient population

Pay for value programs

Incentive payments that are linked to both quality and efficiency improvements

Production hours

Total amount of regular time, overtime, and temporary time. This also may be referred to as actual hours.

Prospective payment system (PPS)

Hospital payment system with predetermined reimbursement ratio for services given

Revenue

Source of income or the reward for providing a service to a patient

Staffing mix

Ratio of registered nurses (RNs), licensed vocational nurses (LVNs)/licensed practical nurses (LPNs), and unlicensed workers (e.g., a shift on one unit might have 40% RNs, 40% LPNs/LVNs, and 20% others).

Third party payment system

System of health care financing in which providers deliver services to patients, and a third party, or intermediary, usually an insurance company or a government agency, pays the bill

Turnover ratio

Rate at which employees leave their jobs for reasons other than death or retirement. The rate is calculated by dividing the number of employees leaving by the number of workers employed in the unit during the year and then multiplying by 100.

Value-based purchasing

Payment methodology that rewards quality of care through payment incentives

Variable costs

Costs that vary with the volume. Payroll costs are an example.

Workload units

• Usually the same as patient-days.

• For some areas it might refer to the number of

  • Procedures

  • Tests

  • Patient visits

  • Injections

Physiological (Maslow’s)

• Breathing

• Food

• Water

• Sex

• Sleep

• Homeostasis

• Excretion

Safety (Maslow’s)

• Security of:

  • Body

  • Employment

  • Resources

  • Morality

  • The family

  • Health

  • Property

Love/Belonging (Maslow’s)

• Friendship

• Family

• Sexual intimacy

Esteem (Maslow’s)

• Self esteem

• Confidence

• Achievement

• Respect of others

• Respect by others

Self-actualization (Maslow’s)

• Morality

• Creativity

• Spontaneity

• Problem solving

• Lack of prejudice

• Acceptance of facts

Internal whistleblowing

Occurs within an organization, reporting up the chain of command

External whistleblowing

Involves reporting outside the organization such as to the media or elected officials

What STDs are nationally reported?

• Syphilis

• Gonorrhea

• Chlamydia

• Chancroid

• HIV

Assault

A threat or attempt

Battery

Successful assault

Defamation

False or exaggerated claims

Invasion of privacy

HIPAA violations

False imprisonment

Unjustified restriction

Fraud

misrepresentation

Employer liability insurance

• Tailored to facility

• Claims-made

• Limited to facility

Personal liability insurance

• Your best interests

• Employer limitations

• Protection outside of employment

Tort

• Wrongdoing that is subject to civil court and is often resolved with a monetary settlement

• Intentional or unintentional

What is a critical pathway

• Strategy for assessing, implementing, and evaluating the cost-effectiveness of patient care.

• Predetermined courses of progress that patients should make after admission for a specific diagnosis or after a specific surgery.

Patient progress that differs from the critical pathway prompts a…

Variance analysis

Advantage of critical pathways

• Provide some means of standardizing care for patients with similar diagnoses.

• Improved patient outcomes and lower costs

Cons of critical pathways

Have trouble accounting for and accepting what are often justifiable differentiations between unique patients who have deviated from their pathway.

Federal agencies

• Department of Health and Human Services (DHHS)

• National Institutes of Health (NIH)

• Centers for Medicare and Medicaid Services

• Food and Drug Administration (FDA)

• Centers for Disease Control and Prevention (CDC)

• Agency for Healthcare Research and Quality (AHRQ)

Morals

Personal or societal standards of right and wrong

Ethics

The study of moral principles or standards governing relationships that is based on professional nursing beliefs and values

Virtues

Human excellence — character and conduct that define good people

Moral agency

The capacity to be ethical and to do the ethically right thing for the right reason

Moral resilience

Developed capacity to respond well to morally distressing experiences and to emerge strong

Moral distress

Occurs when you know the right thing to do, but either personal or institutional factors make it difficult to follow the correct course of action

Moral injury

Occurs when there has been (1) a betrayal of what is right, (2) by someone who holds legitimate authority or by oneself, (3) in a high-stakes situation