Chapter 19: Health Care System: Financing, Issues, and Trends My Nursing Test Banks

Chapter 19: Health Care System: Financing, Issues, and Trends

Test Bank

MULTIPLE CHOICE

1. The nurse is asked by a patient, Why is it necessary to have deductibles and copayments when I already have health insurance? The best response would be

a.

They are a way to improve the margin of profit in the fee-for-service method of paying for health care.

b.

They prevent health care agencies from having huge deficits associated with uncompensated care.

c.

They were developed to save health care dollars at the time Medicare introduced DRGs.

d.

They are part of the incremental changes designed to provide more universal care.

ANS: A

Deductibles and copayments require the patient to pay an increased share of the cost of treatment, thus improving the profit margin for the insurer. They benefit the insurer more than the agency. Deductibles and copayments were not developed to save health care dollars at the time Medicare introduced DRGs. Deductibles and copayments are not part of the incremental changes designed to provide more universal care.

DIF: Cognitive Level: Application REF: p. 241, Box 19-1

OBJ: 1 TOP: Deductibles and copayments

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment

2. A patient tells the nurse, I didnt sign up for health care insurance at my job because Im young and healthy and can use the money in other ways. The response that best explains the advantage of health insurance would be, With insurance

a.

a fiscal middleman pays your health care bills.

b.

your individual contributions go directly to paying your personal expenses.

c.

you can borrow money for unexpected health care expenses at a very low interest rate.

d.

you are spreading the risk in case you have a serious health event, such as cancer or major trauma.

ANS: D

Health insurance, like any insurance, spreads risk. The risk that is spread in health insurance is that the young and the healthy generally subsidize (support financially) the sick and older persons in the health insurance group. Individual contributions are pooled for the protection of individuals from financial disaster due to health care bills. A fiscal middleman does pay health care bills, but this does not address the best explanation of the advantage of health insurance. The remaining options are not factual statements.

DIF: Cognitive Level: Analysis REF: p. 240 OBJ: 2

TOP: Advantage of health insurance KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment

3. A patient asks the nurse, What do health maintenance organizations (HMOs) do to reduce health care costs? The response giving the best example of an HMO cost-containment method would be

a.

HMOs pool individual contributions for use in catastrophic illness.

b.

HMOs provide supplemental coverage for items not covered by Medicare.

c.

HMOs use a retrospective payment system.

d.

HMOs provide services aimed at keeping members healthy.

ANS: D

HMOs attempt to reduce costs by providing services aimed at keeping members healthy, such as smoking cessation classes and weight loss programs. The other options are not factual statements.

DIF: Cognitive Level: Analysis REF: pp. 240-241, Box 19-2

OBJ: 4 TOP: HMOs KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment

4. Which of the following constitutes a problem that affects data collected by the nurse interviewing an elderly, chronically ill patient? Many elderly who are covered only by Medicare Parts A and B find it difficult to pay the cost of

a.

hospital care for an acute short-term illness.

b.

prescription drugs while living at home.

c.

post-hospitalization rehabilitation services in a skilled nursing facility.

d.

doctors office visits, Pap smears, and mammography.

ANS: B

Data collection should include medications prescribed for the patient and whether the patient is medication compliant. Often patients are without medication when funds are limited. The other costs mentioned in the remaining options are covered by Medicare Parts A and B.

DIF: Cognitive Level: Application REF: pp. 242-244, Box 19-6

OBJ: 2 TOP: Medicare coverage

KEY: Nursing Process Step: Assessment (Data Collection)

MSC: NCLEX: Health Promotion and Maintenance

5. When involved with discharge planning for a patient recovering from a mild cerebrovascular accident, the nurse should understand that Medicare provides

a.

longer stays for Medicare patients in acute inpatient settings.

b.

increased use of extended care units for rehabilitation needs.

c.

inappropriate early discharge of large numbers of patients.

d.

universal coverage for U.S. citizens and permanent residents.

ANS: B

Medicare provides for 20 days post-hospitalization care in a skilled nursing facility for rehabilitation services. Medicare patients in acute inpatient settings do not have longer stays. Medicare does not provide universal coverage for U.S. citizens and permanent residents. Inappropriate early discharge of large numbers of patients is not an advantage to a patient.

DIF: Cognitive Level: Application REF: p. 242, Box 19-3

OBJ: 2 TOP: Medicare benefits

KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment

6. Diagnosis-related groups (DRGs) and prospective payment systems are most clearly the reason for

a.

Medicare and Medicaid.

b.

critical pathways and managed care.

c.

group health insurance and centralization.

d.

a shortage of nurses and unlicensed assistive personnel.

ANS: B

Both DRGs and prospective payment systems have resulted in cost-containment efforts by health care agencies. Managed care and critical pathways are responses to the need to contain costs. DRGs originated with Medicare. Group health insurance existed prior to DRGs and prospective payment systems. The reason for personnel shortages in health care is not as simplistic as a shortage of nurses and unlicensed assistive personnel.

DIF: Cognitive Level: Analysis REF: p. 243 OBJ: 5

TOP: Changes associated with DRGs and prospective payment KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

7. A patient tells the nurse, I received a questionnaire that said my answers would be used for purposes of continuous quality improvement. I wonder if its worth my time to fill it out? The response that best explains continuous quality improvement is, Continuous quality improvement activities are used to

a.

restructure hospital departments and personnel assignments to ensure cost savings.

b.

provide an opportunity for staff members to participate in self-governance.

c.

obtain appropriate reimbursement for care given to ambulatory and inpatients.

d.

monitor and improve processes involved in providing safe, effective care for patients.

ANS: D

Continuous quality improvement (CQI) activities provide information critical to total quality management. Feedback from patients is one data collection method for CQI. The other options do not describe CQI activities.

DIF: Cognitive Level: Application REF: p. 246 OBJ: 7

TOP: CQI KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment

8. A 70-year-old patient tells the nurse, I cant go to the hospital for treatment, because I have no hospital insurance. My Social Security and my pension pay my living expenses, but I dont have any savings. The nurses response should be focused on

a.

providing information about Medicare.

b.

explaining the provisions of Medicaid.

c.

exploring the patients ability to purchase group health insurance.

d.

investigating which hospitals provide free care for indigent patients.

ANS: A

It is important to provide information that elderly persons, regardless of income, can receive federal payment for hospital and physician services through Medicare. There is not a clear need to provide information about Medicaid. Its too late to secure group health insurance for this identified health care need. In addition, health insurance companies often refuse payment for treatment of preexisting conditions. Exploring the patients ability to purchase group health insurance should not be the initial focus.

DIF: Cognitive Level: Application REF: p. 242 OBJ: 4

TOP: Medicare benefits KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment

9. A mother and her three children often seek medical services at the emergency room. The nurse realizes that they have no insurance and are unable to pay for services. The action the nurse should take that would provide the greatest assistance to the family would be to

a.

advise them to use urgent care centers where fees are lower.

b.

leave the newspaper classified ads in a visible place.

c.

advise the mother to seek work at the hospital personnel office.

d.

contact a social worker to discuss Medicaid with the mother.

ANS: D

The social worker would be able to help the family explore whether they might qualify for Medicaid or the Childrens Health Insurance Program. Advising the family to use urgent care centers might be considered a form of refusal of services. Leaving the newspaper classified ads in a visible place and advising the mother to seek work at the hospital personnel office assume that the uninsured mother is not working, when in fact she may have a job that does not provide the benefit of health care.

DIF: Cognitive Level: Analysis REF: p. 244 OBJ: 4

TOP: Medicaid KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment

10. Which program offers an incentive to hospitals to discharge patients as quickly as possible?

a.

Retrospective payment system

b.

Prospective payment system

c.

Seamless system

d.

Private insurance plans in effect for under 1 year

ANS: B

The prospective payment system tells the hospital what it will pay for specific health care in advance. This fixed payment does not change regardless of the number of days the patient is hospitalized. Thus, early discharge can result in a profit for the hospital, creating an incentive.

DIF: Cognitive Level: Comprehension REF: p. 244 OBJ: 4

TOP: Prospective payment system KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

11. A trend in health care that may negatively affect the number of practical nurses hired by an agency is

a.

the aging of the U.S. population.

b.

the increased use of unlicensed assistive personnel.

c.

decentralization of health care agencies.

d.

the emphasis on critical thinking and problem solving.

ANS: B

The trend toward using the least expensive personnel to perform nursing care negatively affects the number of licensed nurses employed by an agency. The aging of the population does not negatively affect the hiring of LPN/LVNs. Decentralization of health care agencies is more likely to affect middle managers. Critical thinking and problem-solving abilities make LPN/LVNs more attractive as employees.

DIF: Cognitive Level: Comprehension REF: p. 248 OBJ: 6

TOP: Trends KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

12. Which of the following is a quality improvement activity in which the LPN/LVN engages routinely?

a.

Collecting data for care plan development

b.

Identifying nursing diagnoses

c.

Initiating patient teaching about medications

d.

Evaluating patient goal attainment

ANS: A

The creation of care plans is a major way to improve the quality of patient care. The LPN/LVN assists the RN in the formulation of nursing care plans by contributing relevant data. The LPN/LVN is not responsible for identifying nursing diagnoses, initiating patient teaching about medications, or evaluating goal attainment. These activities are reserved for RNs.

DIF: Cognitive Level: Analysis REF: p. 247 OBJ: 7

TOP: CQI KEY: Nursing Process Step: Assessment (Data Collection)

MSC: NCLEX: Safe, Effective Care Environment

13. Which LPN/LVN will be most successful in dealing with change?

a.

Nurse S, who always assumes that the worst will happen in any situation

b.

Nurse T, who agrees with whatever the administration proposes

c.

Nurse U, who sees change as an opportunity to improve conditions

d.

Nurse V, who predicts that the change will probably not work

ANS: C

The nurse who sees change as an opportunity to be part of the solution to a problem is a navigator, one who feels confident and in control. The navigator fares well in change. The nurse who always assumes that the worst will happen in any situation is a victim who feels helpless during change. Victims do not fare well during times of change. The nurse who sees change as an opportunity to improve are survivors, individuals who go along with change but predict that it will be unsuccessful.

DIF: Cognitive Level: Analysis REF: p. 248 OBJ: 8

TOP: Change KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

14. The skill that will be most helpful to an LPN/LVN in navigating health care system changes successfully is

a.

the ability to work efficiently for long hours.

b.

problem-solving and critical thinking abilities.

c.

identifying the need for comprehensive system change.

d.

becoming knowledgeable about CQI processes.

ANS: B

Critical thinking and problem solving are important not only in patient care, but also in nonclinical situations in the health care agency. The ability to work efficiently for long hours will not promote success during change. Identifying the need for comprehensive system change and becoming knowledgeable about CQI processes will be helpful but would not be assessed as most helpful.

DIF: Cognitive Level: Analysis REF: p. 248 OBJ: 9

TOP: Change KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

15. A set monthly fee charged by the provider of health care services for each member of the insurance group for a specific set of services is known as

a.

inflation.

b.

capitation.

c.

fee-for-service.

d.

gross domestic product.

ANS: B

Capitation is an alternative to the traditional fee-for-service method of payment. Capitation involves a set monthly fees charged by the provider of health care services for each member of the insurance group for a specific set of services. Inflation is a general rise in prices, usually persisting over several years. Fee-for-service is the traditional method of paying health care bills in which physicians are paid a fee by the patient for each service they provide. Gross domestic product is the combination of all goods and services produced in a nations economy.

DIF: Cognitive Level: Comprehension REF: p. 240 OBJ: 1

TOP: Capitation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

16. A method of financing health care costs in which physicians are paid a fee by the patient for each service they provide is known as

a.

inflation.

b.

capitation.

c.

fee-for-service.

d.

gross domestic product.

ANS: C

Fee-for-service is the traditional method of paying health care bills in which physicians are paid a fee by the patient for each service they provide. Inflation is a general rise in prices, usually persisting over several years. Capitation is an alternative to the traditional fee-for-service method of payment. Capitation involves a set monthly fees charged by the provider of health care services for each member of the insurance group for a specific set of services. Gross domestic product is the combination of all goods and services produced in a nations economy.

DIF: Cognitive Level: Comprehension REF: p. 240 OBJ: 1

TOP: Fee-for-service KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

17. The monthly fee a person must pay for health care insurance coverage is known as the

a.

premium.

b.

deductible.

c.

copayment.

d.

coinsurance.

ANS: A

The premium is the monthly fee a person must pay for health care insurance coverage. The deductible is the yearly amount an insured person must spend out-of-pocket for health care services before a health insurance policy will begin to pay its share. The copayment is the amount an insured person must pay at the time of an office visit, when picking up a prescription, or before a hospital service. Coinsurance is the percentage of the total bill paid by the insured person after a deductible has been met. The remainder is paid by the insurance company.

DIF: Cognitive Level: Comprehension REF: p. 241, Box 19-1

OBJ: 2 TOP: Basic health insurance terms KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

18. The yearly amount an insured person must spend out-of-pocket for health care services before a health insurance policy will begin to pay its share is known as the

a.

premium.

b.

deductible.

c.

copayment.

d.

coinsurance.

ANS: B

The deductible is the yearly amount an insured person must spend out-of-pocket for health care services before a health insurance policy will begin to pay its share. The premium is the monthly fee a person must pay for health care insurance coverage. The copayment is the amount an insured person must pay at the time of an office visit, when picking up a prescription, or before a hospital service. Coinsurance is the percentage of the total bill paid by the insured person after a deductible has been met. The remainder is paid by the insurance company.

DIF: Cognitive Level: Comprehension REF: p. 241, Box 19-1

OBJ: 2 TOP: Basic health insurance terms KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

19. The amount an insured person must pay at the time of an office visit, when picking up a prescription, or before a hospital service is known as the

a.

premium.

b.

deductible.

c.

copayment.

d.

coinsurance.

ANS: C

The copayment is the amount an insured person must pay at the time of an office visit, when picking up a prescription, or before a hospital service. The premium is the monthly fee a person must pay for health care insurance coverage. The deductible is the yearly amount an insured person must spend out-of-pocket for health care services before a health insurance policy will begin to pay its share. Coinsurance is the percentage of the total bill paid by the insured person after a deductible has been met. The remainder is paid by the insurance company.

DIF: Cognitive Level: Comprehension REF: p. 241, Box 19-1

OBJ: 2 TOP: Basic health insurance terms KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

20. Once a deductible has been met, the percentage of the total bill paid by the insured person is known as the

a.

premium.

b.

deductible.

c.

copayment.

d.

coinsurance.

ANS: D

Coinsurance is the percentage of the total bill paid by the insured person after a deductible has been met. The remainder is paid by the insurance company. The premium is the monthly fee a person must pay for health care insurance coverage. The deductible is the yearly amount an insured person must spend out-of-pocket for health care services before a health insurance policy will begin to pay its share. The copayment is the amount an insured person must pay at the time of an office visit, when picking up a prescription, or before a hospital service.

DIF: Cognitive Level: Comprehension REF: p. 241, Box 19-1

OBJ: 2 TOP: Basic health insurance terms KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

MULTIPLE RESPONSE

1. A student nurse asked to identify the types of services currently provided in the U.S. health care delivery system should mention which of the following? (Select all that apply.)

a.

Restructuring

b.

Health promotion

c.

Diagnosis and treatment

d.

Illness prevention

e.

Seamless systems

f.

Alliances and networks

ANS: B, C, D

Of the options listed, those considered to be health care services are health promotion, diagnosis and treatment, and illness prevention. The other options are terms used in this chapter.

DIF: Cognitive Level: Knowledge REF: p. 240 OBJ: 1

TOP: Health care services KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

2. Which of the following phrases could be used by a nurse to characterize the present health care delivery system in the United States? (Select all that apply.)

a.

Responds to illness

b.

Is oriented to promote wellness

c.

Provides for universal access

d.

Depends on national health insurance

e.

Is fragmented and confusing

f.

Is unsafe

ANS: A, E, F

The U.S. health care system responds to illness rather than health promotion. Universal access is not available. National health insurance is not available. The system is fragmented, with a variety of payment options and multiple sources of funding and only a few seamless systems in place. The U.S. health care system has been described as a poorly designed, fragmented, and disjointed maze of services that lacks preventive care, wastes resources, and is low quality, unsafe, and confusing.

DIF: Cognitive Level: Comprehension REF: p. 240 OBJ: 4

TOP: U.S. health care system characteristics KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

3. Which of the following are problems associated with the present health care delivery system that could be identified by a nursing student who is writing an essay? (Select all that apply.)

a.

High cost

b.

Insufficient number of doctors

c.

Widespread shortage of RNs

d.

Continuous quality improvement

ANS: A, C

The cost of U.S. health care is higher than in any other developed country16% of our gross national productand there is an identified widespread shortage of professional nurses in both acute and long-term care agencies. There is no identified national shortage of physicians. Continuous quality improvement is not considered a problem, but rather a means for identifying health care problems.

DIF: Cognitive Level: Comprehension REF: p. 245 OBJ: 4

TOP: Problems in the health care delivery system KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

4. The LPN/LVN charge nurse has been designated to participate in the orientation of a new LPN/LVN by explaining cost-containment measures. Measures the charge nurse should mention include which of the following? (Select all that apply.)

a.

Charge patients for all supplies used in their care.

b.

Document patient care according to the policy for reimbursement.

c.

Use time management principles to work efficiently.

d.

Use supplies carefully to avoid waste.

e.

Implement measures to prevent complications.

f.

Advise insured patients to select higher tiers whenever possible.

ANS: A, B, C, D, E

Charging patients for all supplies used, documenting care accurately, using time management principles, using supplies efficiently, and preventing complications all result in cost containment. Advising insured patients to select higher tiers whenever possible would not conserve health care dollars, because higher tier care and medications are more costly than those offered in lower tiers.

DIF: Cognitive Level: Application REF: pp. 246-247 OBJ: 4

TOP: Cost containment KEY: Nursing Process Step: Implementation

MSC: NCLEX: N/A

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