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A nurse working in a pediatric clinic provides codes for a patient's services to a third-party payer who pays all or most of the care. How does the nurse refer to this method of payment?
- A. Out-of-pocket payment
- B. Individual private insurance
- C. Employer-based group private insurance
- D. Government financing
Correct Answer: B
Rationale: The four basic modes of paying for health care are out-of-pocket payment, individual private insurance, employer-based group private insurance, and government financing. With individual private insurance, 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. Out-of-pocket payment is paying for health care with cash payments. Employer-based private insurance is employer-sponsored coverage, and government financing is provided through Medicare and Medicaid, and other federally funded programs.
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A nurse working in a primary care facility prepares insurance forms in which the provider is given a fixed monetary amount per enrollee in the health plan. What term do the nurses apply to this type of reimbursement?
- A. Capitation
- B. Prospective payment system
- C. Bundled payment
- D. Rate setting
Correct Answer: A
Rationale: Capitation plans give providers a fixed amount per enrollee in the health plan to build a payment plan that consists of the best standards of care at the lowest cost. The prospective payment system groups inpatient hospital services for Medicare patients into DRGs. With bundled payments, providers receive a fixed sum of money to provide a range of services. Rate setting means that the government could set targets or caps for spending on health care services.
Nurses provide care to patients in secondary health care facilities. Which patients do the nurses anticipate will receive this type of care? Select all that apply.
- A. Patient seeking treatment at a community clinic for possible strep throat
- B. Patient treated in the hospital following a myocardial infarction
- C. Child brought to the emergency department following a seizure
- D. Individual with osteogenesis imperfecta being treated in a medical center
- E. Child visiting a specialist to correct a congenital heart defect
- F. Patient who has a hernia repair in an ambulatory care center
Correct Answer: B,C,F
Rationale: Secondary health care treats problems that require specialized clinical expertise, such as an MI, a seizure, and a hernia repair. Treating strep throat is primary health care. Tertiary health care involves management of rare and complex disorders, such as osteogenesis imperfecta and congenital heart malformations.
Nursing students are asked to provide interprofessional care during their clinical experience. Which member of the health care team will the student contact for an uninsured patient?
- A. Nurse practitioner
- B. Admissions coordinator
- C. Social worker
- D. Hospital chaplain
Correct Answer: C
Rationale: Social workers assist patients and families in dealing with the social, emotional, and environmental factors that affect their well-being, including making referrals to community resources and assisting with health care finances for uninsured patients. Nurse practitioners manage medical and nursing needs, admissions coordinators handle administrative tasks, and hospital chaplains address spiritual needs.
A nurse researcher follows current trends in health care delivery. Which present-day trends does the nurse observe? Select all that apply.
- A. Globalization of the economy and society
- B. Slowdown in technology development
- C. Decreasing diversity
- D. Increasing complexity of patient care
- E. Changing demographics
- F. Shortages of key health care professionals and educators
Correct Answer: A,D,E,F
Rationale: Trends to watch in health care delivery include globalization of the economy and society, increasing complexity of patient care, changing demographics, shortages of key health care professionals and educators, technology explosion, and increasing diversity. A slowdown in technology development and decreasing diversity are not current trends.
Nursing students are reviewing information about health care delivery systems in post conference. Which statements describing current U.S. health care delivery practices should be included in the discussion? Select all that apply.
- A. Access to care depends only on the ability to pay, not the availability of services.
- B. The Patient Protection and Affordable Care Act provides private health care insurance to underserved populations.
- C. Every health insurance plan in the Health Insurance Marketplace offers comprehensive coverage, from doctors to medications to hospital visits.
- D. The uninsured pay for more than one third of their care out of pocket and are usually charged lower amounts for their care than the insured pay.
- E. Fifty years ago, half of the doctors in the United States practiced primary care, but today fewer than one in three do.
- F. Quality of care can be defined as the right care for the right person at the right time.
Correct Answer: C,E,F
Rationale: The Health Insurance Marketplace is designed to help people more easily find health insurance that fits their budget. All plans in the Marketplace offer comprehensive coverage, from doctors to medications to hospital visits. There are many fewer primary care providers in the United States than there were 50 years ago. Quality is the right care for the right person at the right time. Access to care depends on both the ability to pay and the availability of services. The Patient Protection and Affordable Care Act provides Medicaid or subsidized coverage to qualifying people with incomes up to 400% of poverty. The uninsured pay for more than one third of their care out of pocket and are often charged higher amounts for their care than the insured pay.