Basics Of The U.S. Health Care System 4th Edition By Niles Nancy TEST BANK

Basics of the U.S. Health Care System, Fourth Edition Nancy J. Niles

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Chapter: Chapter 01 - Quiz

True/False

1. True or False? Group insurance is a type of public insurance that anticipates that a large group of individuals will purchase insurance through their employer and the risk is spread among those paying individuals.

Ans: False Complexity: Moderate Ahead: Milestones of the Health Insurance System Subject: Chapter 1 Title: History and Overview of the U.S. Healthcare System

2. True or False? Almshouses, operated by local governments, were used to quarantine people who had contagious diseases such as cholera. These institutions were the predecessor of hospitals.

Ans: False Complexity: Moderate Ahead: Milestones of the Hospital System Subject: Chapter 1 Title: History and Overview of the U.S. Healthcare System

3. True or False? Public health functions are functions that provide services to the community. They target populations rather than individuals. They include child immunization programs, health screenings in schools, community health services, substance abuse programs, and sexually transmitted disease control.

Ans: True Complexity: Easy Ahead: Consumer Perspective on Health Care Subject: Chapter 1 Title: History and Overview of the U.S. Healthcare System

4. True or False? Traditional health functions are functions that provide services to the community. They target populations rather than individuals. They include child immunization programs, health screenings in schools, community health services, substance abuse programs, and sexually transmitted disease

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Basics of the U.S. Health Care System, Fourth Edition Nancy J. Niles

control.

Ans: False Complexity: Moderate Ahead: Consumer Perspective on Health Care Subject: Chapter 1 Title: History and Overview of the U.S. Healthcare System

5. True or False? Almshouses, operated by local governments, were used to quarantine people who had contagious diseases such as cholera. These institutions were the predecessors of hospitals.

Ans: False Complexity: Moderate Ahead: Milestones of the Hospital System Subject: Chapter 1 Title: History and Overview of the U.S. Healthcare System

Short Answer

1. __________ are the foundation of our healthcare system.

Ans: Hospitals Complexity: Moderate Ahead: Milestones of the Hospital System Subject: Chapter 1 Title: History and Overview of the U.S. Healthcare System

2. The __________ Report was responsible for medical school curriculum development and admission standards which are still in existence today.

Ans: Flexner Complexity: Easy Ahead: Consumer Perspective on Health Care Subject: Chapter 1 Title: History and Overview of the U.S. Healthcare System

3. __________ are physicians who provide care to patients while they are hospitalized.

Ans: Hospitalists Complexity: Easy Ahead: Milestones of the Hospital System Subject: Chapter 1 Title: History and Overview of the U.S. Healthcare System

4. The __________ program focuses on the three goals of patient satisfaction, public health improvement and reducing healthcare costs.

Ans: Triple Aim Complexity: Easy Ahead: Milestones of the Hospital System

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Basics of the U.S. Health Care System, Fourth Edition Nancy J. Niles

Subject: Chapter 1 Title: History and Overview of the U.S. Healthcare System

5. Another term for cost sharing of patient’s healthcare expenses is typically called __________.

Ans: out of pocket Complexity: Easy Ahead: Current System Operations Subject: Chapter 1 Title: History and Overview of the U.S. Healthcare System

Essay

1. Select three milestones from the nursing education timeline and discuss how they have impacted the nursing profession.

Student responses will vary.

2. Select two government agencies and their impact on the healthcare industry.

Student responses will vary.

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Basics of the U.S. Health Care System, Fourth Edition Nancy J. Niles

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Chapter: Chapter 02 - Quiz

Multiple Choice

1. Which statement is correct about hospitals?

A) They provide total medical care.

B) Hospitals may specialize in treatments such as children’s health, cancer, and mental health.

C) Many consumers use their emergency departments as their primary care provider.

D) All of these are correct.

Ans: D Complexity: Easy Ahead: Major Stakeholders in the Healthcare Industry Subject: Chapter 2 Title: Current Operations of the U.S. Healthcare System

2. Why are life expectancy rates calculated?

A) They calculate the average life expectancy of a country.

B) They are often used as a comparison measure of a country’s health status.

C) They can be used to compare both male and female life expectancy rates.

D) All of these are correct.

Ans: D Complexity: Difficult Ahead: Healthcare Statistics Subject: Chapter 2 Title: Current Operations of the U.S. Healthcare System

3. What is the difference between the life expectancy of a female and male in the United States?

A) Males typically live longer than females.

B) Females typically live longer than males.

C) Male and female life expectancy rates are decreasing.

D) Male life expectancy rates are increasing only.

Ans: B Complexity: Easy Ahead: Healthcare Statistics Subject: Chapter 2 Title: Current Operations of the U.S. Healthcare System

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Basics of the U.S. Health Care System, Fourth Edition Nancy J. Niles

4. Why is the U.S. hospital beds rate so low?

A) We, as healthcare consumers, prefer inpatient services.

B) We, as healthcare consumes, prefer outpatient services.

C) Hospitals are closing at an alarming rate.

D) Hospital construction is increasing due to the Affordable Care Act. Ans: B Complexity: Moderate Ahead: Healthcare Statistics Subject: Chapter 2 Title: Current Operations of the U.S. Healthcare System

5. Which statement is correct about tobacco use worldwide?

A) Tobacco use kills six million people annually.

B) Approximately 600,000 are killed from secondhand smoke.

C) It is the largest preventable risk factor.

D) All of these are correct.

Ans: D Complexity: Easy Ahead: Healthcare Statistics Subject: Chapter 2 Title: Current Operations of the U.S. Healthcare System

True/False

1. True or False? Complementary and integrative medicine practitioners practice unconventional health therapies such as yoga, vitamin therapy and spiritual healing. These services normally are paid out of pocket by consumers.

Ans: False Complexity: Moderate Ahead: Major Stakeholders in the Healthcare Industry Subject: Chapter 2 Title: Current Operations of the U.S. Healthcare System

2. True or False? Outpatient care centers include kidney dialysis centers, mental health and substance abuse clinics, surgical and emergency centers. These centers provide different types of services that can be obtained without staying overnight.

Ans: True Complexity: Moderate Ahead: Major Stakeholders in the Healthcare Industry Subject: Chapter 2 Title: Current Operations of the U.S. Healthcare System

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Basics of the U.S. Health Care System, Fourth Edition Nancy J. Niles

3. True or False? Residential care facilities provide around the clock social and personal care to the elderly, children, and other who cannot take care of themselves. Examples are assisted living facilities.

Ans: True Complexity: Easy Ahead: Major Stakeholders in the Healthcare Industry Subject: Chapter 2 Title: Current Operations of the U.S. Healthcare System

4. True or False? Residential care facilities provide care to the elderly on a daily basis for approximately 8 hours per day so the caregiver can have a break.

Ans: False Complexity: Moderate Ahead: Major Stakeholders in the Healthcare Industry Subject: Chapter 2 Title: Current Operations of the U.S. Healthcare System

5. True or False? Dementia is the most common form of Alzheimer’s.

Ans: False Complexity: Moderate Ahead: Healthcare Statistics Subject: Chapter 2 Title: Current Operations of the U.S. Healthcare System

Essay

1. What is the National Center for Health Statistics? What activities are they responsible for?

Ans: The National Center for Health Statistics, which is part of the Centers for Disease Control and Prevention, produces an annual report on the health status of the United States. This publication, Health, United States, 2007, provides an overview of healthcare utilization, resources, and expenditures. This publication examines all different aspects of the U.S. healthcare delivery system as well as assessing the health status of U.S. citizens.

Complexity: Moderate Ahead: Healthcare Statistics Subject: Chapter 2 Title: Current Operations of the U.S. Healthcare System

2. Discuss the importance of statistics and why they are calculated. Select three OECD statistics that you can use to compare the United States and one other OECD country. Why did you select these statistics?

Ans: Statistics are calculated to assess healthcare services in the United States. The National Center for Health Statistics, which is part of the CDC, produces an annual report on the health of the nation. Life expectancy rates are calculated to assess health of nation. Infant mortality rates are also calculated to assess health of nation. Student responses will vary with regard to the second part of the question.

Complexity: Difficult Ahead: Healthcare Statistics Subject: Chapter 2 Title: Current Operations of the U.S. Healthcare System

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Basics of the U.S. Health Care System, Fourth Edition Nancy J. Niles

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Chapter: Chapter 03 - Quiz

Multiple Choice

1. Social regulation focuses on: A) organizations’ actions such as those in the healthcare industry that impact individual’s safety. These regulations focus on protecting individuals as employees and consumers.

B) the economic status of healthcare organizations to ensure they help consumers.

C) the social relationship that exists between the consumer and the physician.

D) None of these are correct.

Ans: A Complexity: Easy Ahead: History of the Role of Government in Health Care Subject: Chapter 4 Title: Government’s Role in U.S. Health Care

2. The National Institutes of Health is a federal agency that is responsible for: A) research towards preventing and curing disease.

B) improving access to healthcare services for people who are medically vulnerable.

C) improving the quality, safety, efficiency of health care.

D) improving access to quality substance abuse and mental health services.

Ans: A Complexity: Easy Ahead: U.S. Government Agencies Subject: Chapter 3 Title: Government’s Role in U.S. Health Care

3. The federal agency that is responsible for ensuring that food, human and veterinary products, biological, medical devices, cosmetics and electronic products are safe is the: A) Centers for Disease Control and Prevention.

B) Indian Health Services.

C) Food and Drug Administration.

D) Center for Medicare and Medicaid Services.

Ans: C Complexity: Easy Ahead: U.S. Government Agencies

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Basics of the U.S. Health Care System, Fourth Edition Nancy J. Niles

Subject: Chapter 3 Title: Government’s Role in U.S. Health Care

4. Which agency was established in 1970 to govern the workplace environment to ensure that employees have a safe and healthy environment?

A) Hazard Communication Agency B) Occupational Safety and Health Act C) Occupational Safety and Health Administration D) U.S. Public Health Service Corps Ans: C Complexity: Easy Ahead: U.S. Government Agencies Subject: Chapter 3 Title: Government’s Role in U.S. Health Care

5. Which federal agency was established in 2002 and why?

A) The Federal Emergency Management Agency to monitor U.S. natural disasters B) The Council of State and Territorial Epidemiologists to assess terrorist attacks C) The Department of Homeland Security to oversee any major catastrophic events such as terrorism, natural disasters, and severe weather D) The National Response Framework to provide national policy for emergency management Ans: C Complexity: Easy Ahead: U.S. Government Agencies Subject: Chapter 3 Title: Government’s Role in U.S. Health Care

True/False

1. True or False? The U.S. Constitution gives local government the primary role in healthcare for their citizens. They also license health professionals such as physicians, dentists, chiropractors, nurses, pharmacists, optometrists, and veterinarians who practice within their jurisdiction.

Ans: False Complexity: Moderate Ahead: U.S. Government Agencies Subject: Chapter 3 Title: Government’s Role in U.S. Health Care

2. True or False? Local health departments are the governmental organization that provides most direct services to the population.

Ans: True Complexity: Easy Ahead: U.S. Government Agencies Subject: Chapter 3 Title: Government’s Role in U.S. Health Care

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Basics of the U.S. Health Care System, Fourth Edition Nancy J. Niles

3. True or False? The Health Resource and Services Administration provides access to essential health care services for people who are low income, uninsured, or who live in rural areas or urban neighborhoods where health care is scarce.

Ans: True Complexity: Easy Ahead: U.S. Government Agencies Subject: Chapter 3 Title: Government’s Role in U.S. Health Care

Short Answer

1. The __________ developed behavioral standards for employees who deal with blood products, such as wearing gloves and other equipment, disposal of blood collection materials.

Ans: Occupational Exposure to Bloodborne Pathogen Standard Complexity: Easy Ahead: U.S. Government Agencies Subject: Chapter 3 Title: Government’s Role in U.S. Health Care

2. The __________ was established as a result of the 2001 terrorist attack in New York City.

Ans: Department of Homeland Security Complexity: Easy Ahead: U.S. Government Agencies Subject: Chapter 3 Title: Government’s Role in U.S. Health Care

3. The __________, which is responsible for responding to natural and manmade disasters in the United States, is under the umbrella of the Department of Homeland Security.

Ans: Federal Emergency Management Agency Complexity: Moderate Ahead: U.S. Government Agencies Subject: Chapter 3 Title: Government’s Role in U.S. Health Care

Essay

1. Discuss five direct services provided by local health departments.

Ans: Local health departments provide immunizations to adults and children, conduct communicable/infectious disease surveillance, perform tuberculosis screening, offer tuberculosis treatment, and engage in environmental surveillance.

Complexity: Moderate Ahead: U.S. Government Agencies

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Basics of the U.S. Health Care System, Fourth Edition Nancy J. Niles

Subject: Chapter 3 Title: Government’s Role in U.S. Health Care

2. Discuss the role of the state health department.

Ans: State health departments license health professionals such as physicians, dentists, chiropractors, nurses, pharmacists, optometrists, and veterinarians who practice within the state. They inspect and license healthcare facilities, such as hospitals and nursing homes. Most state agencies provide technical assistance to their local health departments in the following areas: (1) quality improvement, (2) data management, (3) public health law, (4) human resource management, and (5) policy development. State health department provides oversight to local health departments, which are directly responsible for providing public health activities for their community.

Complexity: Moderate Ahead: U.S. Government Agencies Subject: Chapter 3 Title: Government’s Role in U.S. Health Care

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Basics of the U.S. Health Care System, Fourth Edition Nancy J. Niles

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Chapter: Chapter 04 - Quiz

Multiple Choice

1. Which of the following is not a point on the epidemiology triangle?

A) Environment B) Host C) Agent D) Speed Ans: D Complexity: Easy Ahead: The Epidemiology Triangle Subject: Chapter 4 Title: Public Health’s Role in Health Care

2. Which organization was integrated into the Department of Homeland Security to manage catastrophic events such as bioterrorism; chemical and radiation emergencies; mass casualties as a result of explosions, natural disasters, and severe weather; and disease outbreaks?

A) Federal Emergency Management Agency (FEMA) B) National Response Framework (NRF) C) National Incident Management System (NIMS) D) Federal Disaster Response Agency (FDRA) Ans: A Complexity: Moderate Ahead: Emergency Preparedness Subject: Chapter 4 Title: Public Health’s Role in Health Care

3. The CDC has developed national standards for both state and local health departments to develop capabilities to deal with emergencies as part of their strategic plans. Which of the following is not one of the capabilities outlined by the CDC? A) Emergency operations coordination B) Facility management C) Public health laboratory testing D) Surveillance Ans: B

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Basics of the U.S. Health Care System, Fourth Edition Nancy J. Niles

Complexity: Easy Ahead: State and Local Response to Disasters Subject: Chapter 4 Title: Public Health’s Role in Health Care

True/False

1. True or False? The federal health department is responsible for performing the majority of community public health services.

Ans: False Complexity: Easy Ahead: Public Health Infrastructure Subject: Chapter 4 Title: Public Health’s Role in Health Care

2. True or False? The four ‘p’s of marketing are product, price, placement, and promotion.

Ans: True Complexity: Easy Ahead: Public Health Education and Health Promotion Subject: Chapter 4 Title: Public Health’s Role in Health Care

3. True or False? The federal government has endorsed a protocol of “Fight, Run, Hide” if an active shooter is nearby.

Ans: False Complexity: Easy Ahead: Active Shooter Situation Subject: Chapter 4 Title: Public Health’s Role in Health Care

4. True or False? The opioid epidemic began in the 1990s.

Ans: True Complexity: Easy Ahead: Recent Collaboration of Public Health and Private Medicine Subject: Chapter 4 Title: Public Health’s Role in Health Care

5. True or False? The three core public health functions are assessment, policy development, and assurance.

Ans: True Complexity: Easy Ahead: What Is Public Health?

Subject: Chapter 4 Title: Public Health’s Role in Health Care

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Basics of the U.S. Health Care System, Fourth Edition Nancy J. Niles

Short Answer

1. The illegal version of opioids is ____.

Ans: heroin Complexity: Easy Ahead: Recent Collaboration of Public Health and Private Medicine Subject: Chapter 4 Title: Public Health’s Role in Health Care

2. There are four additional ‘p’s of the marketing mix that should be included in a social marketing campaign for a public health issue: Publics, Partnerships, Policy, and _______________.

Ans: Purse strings Complexity: Easy Ahead: Social Marketing Activities Subject: Chapter 6 Title: Public Health’s Role in Health Care

3. __________, a recent concept, focuses on mitigating unnecessary efforts on interventions that do not work and providing care that is medically acceptable.

Ans: Quaternary prevention Complexity: Easy Ahead: What Is Health?

Subject: Chapter 4 Title: Public Health’s Role in Health Care

Essay

1. Discuss the role of the determinants of health on individuals.

Ans: Health has several determinants or influences that impact the status of an individual’s health.

Individual lifestyle factors, such as age, sex, and constitutional factors, are direct determinants of a person’s health. Within the immediate environment of an individual, social and community networks are external influences on health. In addition to the social and community networks, there are the general macroenvironmental conditions of socioeconomic, cultural, and environmental conditions that impact health, such as education, work environment, living and working conditions, healthcare services, food production, unemployment, water and sanitation, and housing. These determinants of health tie into the role of public health in the healthcare delivery system because public health focuses on the impact of these determinants on an individual’s health. Public health provides health education and other preventive activities to consumers so they will understand the negative impact these determinants may have on their health status. These activities are often categorized as primary, secondary, and occasionally tertiary prevention.

Complexity Difficult

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Basics of the U.S. Health Care System, Fourth Edition Nancy J. Niles

Ahead: Determinants of Health Subject: Chapter 4 Title: Public Health’s Role in Health Care

2. Discuss the impact of Chadwick, Snow, and Shattuck on the evolution of public health.

Ans: In 1842, Edwin Chadwick published the Report on the Sanitary Condition of the Labouring Population of Great Britain. His report highlighted the relationship between unsanitary conditions and disease. As Chief Commissioner of the Poor Law Commission, Chadwick was responsible for relief to the poor in England and Wales. He became the champion of reform for working conditions. His report illustrated that the poor had higher rates of disease than the upper class, a fact that still exists today. His activities became the basis for U.S. public health activities. He was also responsible for the implementation of the 1848 Public Health Act, which created England’s first national board of health.

Unfortunately, in 1854, the Parliament did not renew the Act, which consequently dissolved the board of health. Although dissolved, the concept of public health was born because this Act, using data, identified several public health issues that were assigned to national and local boards. Public health issues, such as water, sewerage, environment, safety, and food, were a focus of this Act. By identifying these community issues, people began to focus on improving the community’s health status.

Dr. John Snow, a famed British anesthesiologist, is recognized for investigating the cholera epidemics in London in the 1800s. He made the connection between contaminated water and the spread of cholera.

Dr. Snow surveyed local London residents and discovered that those who were ill had retrieved water from a specific neighborhood pump on Broad Street. When the pump handle was removed, the disease ceased. This famous Broad Street pump incident became a classic example of an epidemiologic investigation that studies the causes between disease and external sources. Lemuel Shattuck, who has been called the architect of the public health infrastructure, wrote the landmark report, Report of the Sanitary Commission of Massachusetts. It was ignored for many years, but finally, in the 19th century, it became central to the development of state and local public health activities. As a result of their work, public health law was enacted and, by the 1900s, public health departments Complexity: Moderate Ahead Origins of Public Health Subject: Chapter 4 Title: Public Health’s Role in Health Care

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Chapter: Chapter 05 - Quiz

Multiple Choice

1. Telemedicine is a new model for delivering healthcare. Which of the following can patients NOT receive through telemedicine?

A) Specialist referral B) Remote patient monitoring C) Medical education D) Emergency treatment Ans: D Complexity: Easy Ahead: Other Health Services Subject: Chapter 5 Title: Inpatient and Outpatient Services

2. Patients who have a lasting life-threatening illness typically receive long-term care in which type of health facility?

A) Respite care B) Hospice care C) Emergency room D) Clinics Ans: B Complexity: Easy Ahead: Other Health Services Subject: Chapter 5 Title: Inpatient and Outpatient Services

3. Which of the following is another term for respite care?

A) Senior care B) Social daycare C) Temporary care program D) Employee assistance programs Ans: C Complexity: Easy Ahead: Other Health Services

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Basics of the U.S. Health Care System, Fourth Edition Nancy J. Niles

Subject: Chapter 5 Title: Inpatient and Outpatient Services

4. Which of the following populations is more likely to use hospital emergency rooms for their healthcare?

A) Indigent population B) The elderly C) Medicaid recipients D) All of these are correct.

Ans: D Complexity: Easy Ahead: Outpatient Services Subject: Chapter 5 Title: Inpatient and Outpatient Services

5. A typical hospice team includes which of the following?

A) Clergy B) Physicians and nurses C) Social workers D) All of these are correct.

Ans: D Complexity: Easy Ahead: Other Health Services Subject: Chapter 5 Title: Inpatient and Outpatient Services

True/False

1. True or False? Women represent a larger portion of the elder population.

Ans: True Complexity: Easy Ahead: Other Health Services Subject: Chapter 5 Title: Inpatient and Outpatient Services

2. True or False? The federal government oversees the licensure of healthcare facilities, including hospitals.

Ans: False Complexity: Easy Ahead: Hospital Licensure, Certification, and Accreditation Subject: Chapter 5 Title: Inpatient and Outpatient Services

3. True or False? Urban hospitals tend have financial issues because they see more poor and elderly patients than rural hospitals.

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Basics of the U.S. Health Care System, Fourth Edition Nancy J. Niles

Ans: False Complexity: Easy Ahead: Other Hospital Classifications Subject: Chapter 6 Title: Inpatient and Outpatient Services

4. True or False? Public hospitals are the oldest type of hospital and are owned by the federal, state, or local government.

Ans: True Complexity: Easy Ahead: Hospital Types by Ownership Subject: Chapter 5 Title: Inpatient and Outpatient Services

5. True or False? Telemedicine is most frequently used in pathology and radiology.

Ans: True Complexity: Easy Ahead: Other Health Services Subject: Chapter 5 Title: Inpatient and Outpatient Services

6. True or False? Inpatient services are services that involve patients who have overnight stays.

Ans: True Complexity: Easy Ahead: Introduction Subject: Chapter 5 Title: Inpatient and Outpatient Services

7. True or False? Hospitals with AMA-approved graduate resident programs are called teaching hospitals.

Ans: True Complexity: Easy Ahead: Other Hospital Classifications Subject: Chapter 5 Title: Inpatient and Outpatient Services

8. True or False? A short stay or acute care hospital focuses on patients who stay on an average of less than 30 days.

Ans: True Complexity: Easy Ahead: Other Hospital Classifications Subject: Chapter 5 Title: Inpatient and Outpatient Services

9. True or False? State governments oversee the licensure of healthcare facilities including hospitals.

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Basics of the U.S. Health Care System, Fourth Edition Nancy J. Niles

Ans: True Complexity: Easy Ahead: Hospital Licensure, Certification, and Accreditation Subject: Chapter 5 Title: Inpatient and Outpatient Services

Short Answer

1. _______ is a 90-year-old U.S.-based organization that provides services to men, women, and teenagers regarding sexual health and family planning.

Ans: Planned Parenthood Complexity: Easy Ahead: Other Health Services Subject: Chapter 5 Title: Inpatient and Outpatient Services

2. According to the Office of Personnel Management, _________ are voluntary, work-based programs that offer free and confidential assessments, short-term counseling, referrals, and follow-up services to employees who have personal and/or work-related problems.

Ans: employee assistance programs (EAPs) Complexity: Moderate Ahead: Outpatient Services Subject: Chapter 5 Title: Inpatient and Outpatient Services

3. As part of the Medicare Rural Hospital Flexibility Program (MRHFP), __________ is a mechanism that allows for capital costs which enables these facilities to expand.

Ans: cost plus reimbursement Complexity: Easy Ahead: Other Hospital Classifications Subject: Chapter 5 Title: Inpatient and Outpatient Services

4. __________ developed by Motorola, uses statistics to identify and eliminate defects in patient care. This approach, developed by Motorola, uses statistics to identify and eliminate defects in patient care.

Ans: Lean Six Sigma Complexity: Easy Ahead: Current Status of Hospitals Subject: Chapter 5 Title: Inpatient and Outpatient Services

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Basics of the U.S. Health Care System, Fourth Edition Nancy J. Niles

5. __________, used by the Institute for Healthcare Improvement, is a four-step cycle focused on improvement of workflow in the healthcare industry.

Ans: PDSA—Plan, do, study, act Complexity: Easy Ahead: Current Status of Hospitals Subject: Chapter 5 Title: Inpatient and Outpatient Services

Essay

1. What is the purpose of the PDSA model?

Ans: PDSA stands for plan, do, study, act. The PDSA model focuses on changing a process to improve the process. Providers plan change in a workflow (step 1); do, or implement, the change (step 2); study and summarize what happened with the change (step 3); and then act upon the change (step 4). Many large U.S. hospitals are working with the Joint Commission Center for Transforming Healthcare to implement processes that target safe and quality patient care. For example, PDSA can be used to reduce medication errors by analyzing the process of providing medications, determining what changes need to be made, and assessing if the changes were successful by the reduction of medication errors.

Complexity: Easy Ahead: Current Status of Hospitals Subject: Chapter 5 Title: Inpatient and Outpatient Services

2. What is the importance of Leapfrog to the healthcare industry?

Ans: The Leapfrog Group was established in 1998 by several large employers that purchase healthcare to find ways to assess the quality of healthcare services. The founders believed they could take “leaps” forward with their employees by rewarding hospitals that achieve quality and safety performance. In 2001, the Leapfrog Group initiated an annual hospital survey, endorsed by the National Quality Forum, to assess hospital safety performance standards to reduce preventable medical mistakes. The surveys can be voluntarily completed by any U.S. hospital and are implemented annually. The survey data are for public consumption so consumers can find out which safety issues are occurring in their local hospitals.

In June 2012, the Leapfrog Group initiated the Hospital Safety Score, a letter-grade rating of how well hospitals protect patients from accidents, infections, injuries and errors. These data are collected from the Leapfrog Hospital Survey, the CMS, and the American Hospital Association to calculate a letter grade safety rating.

Complexity: Easy Ahead: Current Status of Hospitals Subject: Chapter 5 Title: Inpatient and Outpatient Services

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Chapter: Chapter 06 - Quiz

Multiple Choice

1. When was the Social Security Act passed?

A) 1915 B) 1935 C) 1950 D) 1985 Ans: B Complexity: Easy Ahead: Nursing Home Services, 1935–1968 Subject: Chapter 6 Title: Long-Term Care Services

2. Which of the following established a Commission on Long-Term Care?

A) American Taxpayer Relief Act B) American Act Caregiver Program C) The Deficit Reduction Act D) Nursing Home Reform Act Ans: A Complexity: Difficult Ahead: 2010 Healthcare Reform Subject: Chapter 6 Title: Long-Term Care Services

3. What is an annuity?

A) A one-time payment B) A copay in addition to usual costs C) A series of payments over a specified period of time D) A yearly payment Ans: C Complexity: Easy Ahead: How to Pay for Long-Term Care Services Subject: Chapter 6 Title: Long-Term Care Services

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Basics of the U.S. Health Care System, Fourth Edition Nancy J. Niles

True/False

1. True or False? Accelerated death benefits are available if the policy holder lives permanently in a nursing home, is terminally ill, needs long-term care for an extended period of time, or has a lifethreatening diagnosis, such as AIDS. Ans: True Complexity: Easy Ahead: How to Pay for Long-Term Care Services Subject: Chapter 6 Title: Long-Term Care Services

2. True or False? Activities of daily living include bathing, dressing, eating, and going to the bathroom.

Ans: True Complexity: Easy Ahead: Introduction Subject: Chapter 6 Title: Long-Term Care Services

3. True or False? The Mental Health Systems Act of 1980 required states to develop a nursing home ombudsman program and to develop community-care alternatives to institutional care.

Ans: False Complexity: Easy Ahead: Development of Community-Based Services Subject: Chapter 6 Title: Long-Term Care Services

4. True or False? The Nursing Home Reform Act imposed quality standards for nursing homes in order to receive reimbursements from Medicare and Medicaid.

Ans: True Complexity: Easy Ahead: Development of Community-Based Services Subject: Chapter 6 Title: Long-Term Care Services

5. True or False? Assisted-living facilities provide supervision and assistance during normal business hours only.

Ans: False Complexity: Easy Ahead: Types of Long-Term Care Services Subject: Chapter 6 Title: Long-Term Care Services

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Short Answer

1. The _____ programs (1965) are federal programs that provide home- and community-based services to older adults.

Ans: Older Americans Act Complexity: Easy Ahead: How to Pay for Long-Term Care Services Subject: Chapter 6 Title: Long-Term Care Services

2. __________ are support services that include adult day care centers, meal programs such as Meals on Wheels, senior centers, and transportation.

Ans: Community services Complexity: Easy Ahead: Types of Long-Term Care Services Subject: Chapter 6 Title: Long-Term Care Services

3. __________ are a combination of independent living, assisted living, and nursing care all on one campus.

Ans: Continuing care retirement communities (CCRCs) Complexity: Easy Ahead: Current Trends in Long-Term Care Subject: Chapter 6 Title: Long-Term Care Services

Essay

1. What are the four different categories of “life care” contracts within a CCRC, and how do they differ?

Ans: Extensive contracts include housing, residential services, amenities, and unlimited access to health care at budgeted monthly rates. A modified contract includes housing, residential services, and amenities but only limited healthcare access. A fee-for-service contract includes housing, residential services, and amenities but no healthcare services. A rental agreement contract on a monthly or annual basis does not give the resident access to healthcare services.

Complexity: Moderate Ahead: Current Trends in Long-Term Care Subject: Chapter 6 Title: Long-Term Care Services

2. What is Beacon Hill Village?

Ans: Beacon Hill Village is a nonprofit organization started by the Village Movement that formed a network to provide services to older homeowners that allows them to remain in their homes longer and maintain their independence. The network typically acts as a liaison to connect homeowners to needed

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workers.

Complexity: Easy Ahead: Current Trends in Long-Term Care Subject: Chapter 6 Title: Long-Term Care Services

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Chapter: Chapter 07 - Quiz

True/False

1. True or False? Registered nurses can only be licensed in one state.

Ans: False Complexity: Easy Ahead: Types of Nurses Subject: Chapter 7 Title: Careers in the Health Industry

2. True or False? A hospitalist is a physician who specifically proves care to patients while they are in the hospital.

Ans: True Complexity: Easy Ahead: Physician Education Subject: Chapter 7 Title: Careers in the Health Industry

3. True or False? Chiropractors have a holistic approach to treating their patients, which means they focus on the entire body with emphasis on the spine.

Ans: True Complexity: Easy Ahead: Other Independent Healthcare Professionals Subject: Chapter 7 Title: Careers in the Health Industry

4. True or False? Physician assistants can act as primary providers when there is a shortage of physicians.

Ans: True Complexity: Easy Ahead: Physician Education Subject: Chapter 7 Title: Careers in the Health Industry

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5. True or False? Psychologists study the human mind and human behavior. Some psychologists work independently, doing research or working only with patients.

Ans: True Complexity: Easy Ahead: Other Independent Healthcare Professionals Subject: Chapter 7 Title: Careers in the Health Industry

6. True or False? Specialists can be primary care physicians, family care practitioners, general internal medicine physicians, or general pediatricians.

Ans: False Complexity: Easy Ahead: Physician Education Subject: Chapter 7 Title: Careers in the Health Industry

7. True or False? Nurses must earn a bachelor’s degree to become a registered nurse.

Ans: False Complexity: Moderate Ahead: Types of Nurses Subject: Chapter 7 Title: Careers in the Health Industry

8. True or False? The general term nonphysician practitioner (NPP) includes nonphysician clinicians (NPCs) and midlevel practitioners (MLPs).

Ans: True Complexity: Moderate Ahead: Physician Education Subject: Chapter 7 Title: Careers in the Health Industry

9. True or False? Certified nurse-midwives are primary care providers for patients who are pregnant.

Ans: True Complexity: Easy Ahead: Types of Nurses Subject: Chapter 7 Title: Careers in the Health Industry

10. True or False? Generalists can be primary care physicians, family care practitioners, general internal medicine physicians, or general pediatricians.

Ans: True Complexity: Easy

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Ahead: Physician Education Subject: Chapter 7 Title: Careers in the Health Industry

11. True or False? It is important to mention the general term nonphysician practitioner (NPP), which includes nonphysician clinicians (NPCs) and midlevel practitioners (MLPs) and also referred to as physician expanders.

Ans: False Complexity: Moderate Ahead: Physician Education Subject: Chapter 7 Title: Careers in the Health Industry

12. True or False? Registered nurses can only be licensed in one state.

Ans: False Complexity: Easy Ahead: Types of Nurses Subject: Chapter 7 Title: Careers in the Health Industry

13. True or False? Chiropractors have a holistic approach to treating their patients, which means they focus on the entire body with emphasis on the spine although they can prescribe drugs.

Ans: False Complexity: Easy Ahead: Other Independent Healthcare Professionals Subject: Chapter 7 Title: Careers in the Health Industry

14. True or False? Psychologists study the human mind and human behavior. Some psychologists work independently, doing research or working only with patients.

Ans: True Complexity: Easy Ahead: Other Independent Healthcare Professionals Subject: Chapter 7 Title: Careers in the Health Industry

Essay

1. Discuss the difference between an MD and a DO as it relates to their treatment philosophy and education.

Ans: Physicians must receive their medical education from an accredited school that awards either a Doctor of Medicine (MD) or a Doctor of Osteopathic Medicine (DO) degree. Many students prepare for medical school by majoring in a premedical undergraduate program, which often consists of science and mathematics. Undergraduate students are also required to take the Medical College Admission Test

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(MCAT). To provide direct patient care, the physician must take a licensing examination in the desired state of practice once he or she completes a residency. State licensing requirements may vary. The residency is important because it allows physicians to learn about a certain specialty of interest while providing them with on-the-job training. The length of the residency program can be as short as 3 years for a family practice and as long as 10 years for different surgery specialties. Residency programs can be hospital based, community based, or university affiliated. The American Medical Association has an online database of all accredited residency programs by state and location. Most states require physicians to participate in continuing medical education activities to maintain state licensure. The major difference between an MD and a DO is in their treatment approaches. DOs, who are typically generalists, tend to stress preventive treatments and use a holistic approach to treatment, which means they do not focus only on the disease but on the entire person. MDs use an allopathic approach, which means MDs actively intervene in attacking and eradicating disease, and they focus their efforts on the disease. Most MDs are considered specialists.

Complexity: Moderate Ahead: Physician Education Subject: Chapter 7 Title: Careers in the Health Industry

2. Discuss the role of psychologists in the healthcare industry and the different types of specialties.

Ans: Psychologists study the human mind and human behavior. Research psychologists investigate the physical, cognitive, emotional, or social aspects of human behavior. Psychologists in health service fields provide mental health care in hospitals, clinics, schools, or private settings. Psychologists are employed in applied settings, such as business, industry, government, or nonprofit organizations and provide training, conduct research, design organizational systems, and act as advocates for psychology. They usually specialize in one of several different areas. The average median salary for psychologists was $77,030 in 2017.

Clinical psychologists—who represent the largest specialty—work most often in counseling centers, independent or group practices, hospitals, or clinics. Counseling psychologists use various techniques, including interviewing and testing, to advise people on how to deal with career or work problems and problems that occur at different stages of life. Industrial–organizational psychologists apply psychological principles and research methods to the workplace to improve productivity and the quality of work life.

Developmental psychologists study the physiologic, cognitive, and social development that takes place throughout life. Social psychologists examine people’s interactions with others and with the social environment. Experimental or research psychologists work in university and private research centers and in business, nonprofit, and government organizations.

A doctoral degree is usually required for independent practice as a psychologist. Psychologists with a PhD or Doctor of Psychology (PsyD) degree qualify for a wide range of teaching, research, clinical, and counseling positions in universities, healthcare services, elementary and secondary schools, private industry, and government. Psychologists with these doctoral degrees (PhD or PsyD) often work in clinical positions or in private practices, but they may teach, conduct research, or become administrators. These doctoral degrees generally require 5–7 years of graduate study, culminating in a dissertation based on original research. The PsyD degree may be based on practical work and examinations rather than a dissertation. In clinical, counseling, and school psychology, the requirements for these degrees include at least a 1-year internship.

Complexity: Moderate Ahead: Other Independent Health Professionals Subject: Chapter 7 Title: Careers in the Health Industry

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Chapter: Chapter 08 - Quiz

Multiple Choice

1. What is the purpose of the Physician Compare website?

A) It allows healthcare consumers to review information about the quality of the physician.

B) It allows consumers to find out which physicians accept Medicare.

C) It allows consumers to find out how much their insurance will cover.

D) All of these are correct.

Ans: B Complexity: Easy Ahead: ACA’s Legal Issues Subject: Chapter 8 Title: Healthcare Payors and Financing

2. Why did states sue the federal government over the passage of the Affordable Care Act? A) States questioned the constitutionality of requiring individuals to purchase healthcare insurance.

B) States questioned the mandate of requiring states to expand their Medicaid coverage.

C) States questioned the constitutionality of requiring individuals to purchase healthcare insurance and states questioned the mandate of requiring states to expand their Medicaid coverage.

D) States disputed the increase of the age of dependent coverage to age 26.

Ans: C Complexity: Moderate Ahead: ACA’s Legal Issues Subject: Chapter 8 Title: Healthcare Payors and Financing

3. What is the purpose of the Pre-Existing Condition Insurance Plan (PCIP)?

A) Provides health insurance coverage to individuals who have preexisting conditions and had no health insurance for 6 months.

B) Provides health insurance coverage to individuals who have retired early and have no health insurance coverage until they are eligible for Medicare.

C) Provides health insurance coverage to those individuals who are not eligible for either Medicare or Medicaid.

D) None of these are correct.

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Ans: A Complexity: Easy Ahead: Discussion of Major Mandates Subject: Chapter 8 Title: Healthcare Payors and Financing

True/False

1. True or False? Most insurance policies require a contribution from the covered individual such as a copayment, deductible, or coinsurance, which is called cost participation.

Ans: False Complexity: Easy Ahead: Cost Sharing of Health Services Subject: Chapter 8 Title: Healthcare Payors and Financing

2. True or False? Medicare is an entitlement program because after paying into the program for years, people are entitled to receive benefits.

Ans: True Complexity: Easy Ahead: Public Financing of Healthcare Services Subject: Chapter 8 Title: Healthcare Payors and Financing

3. True or False? Medicare is a program based on an individual’s income.

Ans: False Complexity: Moderate Ahead: Types of Health Insurance Subject: Chapter 8 Title: Healthcare Payors and Financing

4. True or False? Managed care plans are a type of health program that combines administrative costs and service costs for cost control.

Ans: True Complexity: Easy Ahead: Types of Health Insurance Subject: Chapter 8 Title: Healthcare Payors and Financing

5. True or False? Medicare Part B is primarily financed from payroll taxes and is considered hospital insurance.

Ans: False Complexity: Moderate Ahead: Public Financing of Healthcare Services

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Subject: Chapter 8 Title: Healthcare Payors and Financing

6. True or False? Medicare Part B is also referred to as Medicare Advantage, and it can be considered a managed care model.

Ans: False Complexity: Easy Ahead: Public Financing of Healthcare Services Subject: Chapter 8 Title: Healthcare Payors and Financing

7. True or False? Accountable care organizations (ACOs) are groups of providers and hospitals who volunteer to give coordinated care to Medicare patients.

Ans: True Complexity: Easy Ahead: Governmental Reimbursement Methods for Healthcare Services Subject: Chapter 8 Title: Healthcare Payors and Financing

8. True or False? Used in both fee for service and prepaid plans, copayments are costs that the patient must pay at the time they receive the services. It is a designated dollar amount.

Ans: True Complexity: Easy Ahead: Cost Sharing of Health Services Subject: Chapter 8 Title: Healthcare Payors and Financing

9. True or False? A recent trend in health insurance plans is consumer-driven health plans that are taxadvantaged plans with high-deductible coverage. The most common CDHPs are health reimbursement arrangements (HRAs) and health savings accounts (HSAs).

Ans: True Complexity: Easy Ahead: Types of Health Insurance Plans Subject: Chapter 8 Title: Healthcare Payors and Financing

10. True or False? The Independence at Home program will provide Medicare beneficiaries with at home primary care and allocated any cost savings of this type of care to the healthcare professionals if they reduce hospital admissions and improve health outcomes.

Ans: True Complexity: Easy Ahead: ACA’s Legal Issues Subject: Chapter 8 Title: Healthcare Payors and Financing

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Basics of the U.S. Health Care System, Fourth Edition Nancy J. Niles

11. True or False? The Nurse Compare website is established to help consumers with research about their physicians.

Ans: False Complexity: Moderate Ahead: Governmental Reimbursement Methods for Healthcare Services Subject: Chapter 8 Title: Healthcare Payors and Financing

12. True or False? The National Institute of Health is establishing the Cures Acceleration Network which is a grants center to encourage research in the cure and treatment of diseases.

Ans: True Complexity: Easy Ahead: ACA’s Legal Issues Subject: Chapter 8 Title: Healthcare Payors and Financing

13. True or False? All insurance falls under these three categories: voluntary, social, and private.

Ans: False Complexity: Moderate Ahead: Types of Health Insurance Subject: Chapter 8 Title: Healthcare Payors and Financing

14. True or False? Copayments are costs that patients must pay at the time they receive a service.

Ans: True Complexity: Easy Ahead: Cost Sharing of Health Services Subject: Chapter 8 Title: Healthcare Payors and Financing

15. True or False? The Affordable Care Act requires most U.S. citizens and legal residents to purchase health insurance whether they can afford it or not or pay a penalty.

Ans: False Complexity: Moderate Ahead: Discussion of Major Mandates Subject: Chapter 8 Title: Healthcare Payors and Financing

16. True or False? The Affordable Care Act requires insurance companies to cover young adults on their parents’ insurance until age 26, even if they are not living with their parents, are not declared dependents on their parents’ taxes, or are no longer students.

Ans: True Complexity: Easy Ahead: Discussion of Major Mandates Subject: Chapter 8

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Title: Healthcare Payors and Financing

17. True or False? The two main types of insurance plans are indemnity plans and point-of-service plans.

Ans: True Complexity: Moderate Ahead: Types of Health Insurance Plans Subject: Chapter 8 Title: Healthcare Payors and Financing

18. True or False? There is no specific type of insurance that covers long term care services.

Ans: False Complexity: Moderate Ahead: Types of Health Insurance Plans Subject: Chapter 8 Title: Healthcare Payors and Financing

Short Answer

1. In a managed care organization, the organization reimburses the provider at a(n) __________, which means they receive a set rate for serving enrolled patients regardless of how much care the provider gives.

Ans: capitated rate Complexity: Easy Ahead: Reimbursement Methods of Private Health Insurance Plans Subject: Chapter 8 Title: Healthcare Payors and Financing

2. A type of copayment, __________ is part of a fee-for-service policy where the patient pays a percentage of the cost of the services.

Ans: coinsurance Complexity: Easy Ahead: Cost Sharing of Health Services Subject: Chapter 8 Title: Healthcare Payors and Financing

Essay

1. Discuss the development of Samaritan ministries.

Ans: In the late 1980s, Samaritan Ministries’ founder, Ted Pittenger, joined a healthcare-sharing ministry and was inspired by the potential for this noninsurance option to provide Biblical, affordable health care for the Christian community.

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Healthcare sharing is a way that Christians are paying for their health care without using health insurance. When they have a medical need, Samaritan members receive support from other members and pay their healthcare providers directly from other members. Members pay a monthly share to a member in need. In order to facilitate the direct healthcare-sharing model, 1 month per year each household’s share amount goes to support the administrative staff and functions of the ministry. As a result of this success, more medical sharing plans have been developed by Christian specialists. For some plans, the member does not have to be a Christian.

Complexity: Moderate Ahead: Samaritan Ministries Subject: Chapter 8 Title: Healthcare Payors and Financing 2. Provide an overview of the ACA Health Insurance Marketplace and the different levels of plans.

Ans: Health Insurance Marketplaces, run by the federal or state governments, are central locations for healthcare consumers to purchase health insurance coverage. They provide standardized information on the different types of health insurance coverage to suit consumer needs. Consumers complete an application to determine the types of coverage available to them, based on their need. Health insurance coverage is provided by private health insurance companies.

If individuals did not apply for health insurance coverage during the open enrollment period, they were required to pay a fee and they cannot obtain coverage until the next annual open enrollment. However, if a life-qualifying event, such as job change or geographic change, occurred, they could be eligible to enroll at other times. The 2014 fee was 1% of the individual’s yearly income or $95 per person, whichever was higher. The fee for an uninsured child was $47.50. The maximum amount a family would pay is $285. The fee increases every year. Individuals who have very low income, who participate in a religious sect that does not believe in health insurance, or who are part of a federally recognized Indian tribe, will not be charged a fee.

Health insurance plans in the Marketplaces must offer at a minimum the following essential health benefits: ambulatory patient services (services that outpatient care individuals receive without being admitted to a hospital), emergency services, hospitalization (such as surgery, maternity and newborn care, i.e., care before and after a baby is born), mental health and substance-use disorder services, including behavioral health treatment (this includes counseling and psychotherapy), prescription medications, rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills), laboratory services, preventive and wellness services, chronic disease management, and pediatric services.

Consumers complete an application to determine the types of coverage available to them, based on their need. Health insurance coverage is provided by private health insurance companies. Generally, the bronze levels have the lowest premiums but have the higher out-of-pocket expenses. The gold and platinum levels have the highest premiums but the lowest out-of-pocket expenses.

Complexity: Difficult Ahead: Health Insurance Marketplaces Subject: Chapter 8 Title: Healthcare Payors and Financing

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Chapter: Chapter 09 - Quiz

Multiple Choice

1. What are physician hospital organizations?

A) They are healthcare providers that contract with MCOs to provide services to their members.

B) They restrict MCO members to a list of providers they can use for care.

B) They are the gatekeeper for all members’ services.

D) All of these are correct.

Ans: A Complexity: Moderate Ahead: History of Managed Care Subject: Chapter 9 Title: Managed Care Impact on Healthcare Delivery

2. Since the late 1980s, which organization has been reviewing and accrediting managed care organizations?

A) Medicare Deemed Status Association B) American Health Association C) American Medical Association D) Accreditation Association for Ambulatory Health Care Ans: D Complexity: Easy Ahead: Managed Care Accreditation Subject: Chapter 9 Title: Managed Care Impact on Healthcare Delivery

3. Medicare cost plans: A) are a type of HMO. B) allow members to seek out-of-network care.

C) have similar rules to Medicare Advantage plans.

D) All of these are correct.

Ans: D Complexity: Moderate Ahead: Medicare and Medicaid Managed Care Subject: Chapter 9

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Basics of the U.S. Health Care System, Fourth Edition Nancy J. Niles

Title: Managed Care Impact on Healthcare Delivery 4. Which of the following are cost-control measures of managed care organizations?

A) Restrictions on provider choices.

B) Establishing a gate keeper or primary care provider as the coordinator of their patient’s services.

C) A review of the different types of services being provided.

D) All of these are correct.

Ans: D Complexity: Easy Ahead: Cost-Control Measures of MCOs Subject: Chapter 9 Title: Managed Care Impact on Healthcare Delivery

True/False

1. True or False? If a physician is an employee of a managed care organization, the MCO will pay the physician’s salary and bonuses based on performance.

Ans: True Complexity: Moderate Ahead: The MCO Payment Plan Subject: Chapter 9 Title: Managed Care Impact on Healthcare Delivery

2. True or False? As the types of MCOs have evolved over the years, the restrictions have lessened, but there is a financial penalty such as a higher copayment or higher deductible for choosing a provider outside of the network.

Ans: True Complexity: Easy Ahead: Cost-Control Measures of MCOs Subject: Chapter 9 Title: Managed Care Impact on Healthcare Delivery

3. True or False? Increasing numbers of states are using Managed Long Term Services and Supports (MLTSS) as a strategy for expanding home- and community-based services to ensure quality and increase efficiency.

Ans: True Complexity: Easy Ahead: Medicare and Medicaid Managed Care Subject: Chapter 9 Title: Managed Care Impact on Healthcare Delivery

4. True or False? The concept of managed care has been evolving since the early 1930s.

Ans: True Complexity: Moderate Ahead: History of Managed Care

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Subject: Chapter 9 Title: Managed Care Impact on Healthcare Delivery

5. True or False? The Affordable Care Act of 2010 mandates that health insurance companies must spend 80%–85% of their premium revenues on quality health care.

Ans: True Complexity: Easy Ahead: Issues with Managed Care Operations Subject: Chapter 9 Title: Managed Care Impact on Healthcare Delivery

6. True or False? Silent PPOs are unauthorized third parties outside the contract between the MCO and the physician that gain access to the MCO discount rates.

Ans: True Complexity: Moderate Ahead: Issues with Managed Care Operations Subject: Chapter 9 Title: Managed Care Impact on Healthcare Delivery

7. True or False? In some managed care organizations, the primary care provider is considered a gatekeeper of all care for the patient member.

Ans: True Complexity: Easy Ahead: Cost-Control Measures of MCOs Subject: Chapter 9 Title: Managed Care Impact on Healthcare Delivery

8. True or False? Another term for Medicare Part C is Medicare Supplemental Plan.

Ans: False Complexity: Easy Ahead: The MCO Payment Plan Subject: Chapter 9 Title: Managed Care Impact on Healthcare Delivery

9. True or False? “Carve-ins” are extra services that Medicaid will pay for under an MCO contract.

Ans: False Complexity: Easy Ahead: Medicare and Medicaid Managed Care Subject: Chapter 9 Title: Managed Care Impact on Healthcare Delivery

Short Answer

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Basics of the U.S. Health Care System, Fourth Edition Nancy J. Niles

1. __________ are services such as experimental treatments that Medicaid is not obligated to pay for because they may be too expensive.

Ans: Carve outs Complexity: Easy Ahead: Medicare and Medicaid Managed Care Subject: Chapter 9 Title: Managed Care Impact on Healthcare Delivery

2. In some MCOs, the primary care provider is the __________ of all of the care for the patient member.

Ans: gatekeeper Complexity: Easy Ahead: Cost-Control Measures of MCOs Subject: Chapter 9 Title: Managed Care Impact on Healthcare Delivery

Essay

1. Discuss the cost-control measures used by managed care organizations.

Ans: Restriction on Provider Choice: Members of an MCO often have restrictions on their choice for a provider. As the types of MCOs have evolved over the years, the restrictions have lessened, but there is a financial penalty, such as a higher copayment or a higher deductible for choosing a provider outside the network.

Gatekeeper: In some MCOs, the primary care provider is the gatekeeper of all of the care for the patient member. Any secondary or tertiary care would be coordinated by the gatekeeper or primary care provider. The primary care provider is responsible for the case management of a member patient. If additional medical services are needed, the primary care provider must refer the member patient for additional services. Some members do not like having a gatekeeper and would prefer to make these decisions themselves. As a result of this model, some MCOs require a preauthorization of services by the MCO. Many MCOs have clinical guidelines to determine service approval.

Services Review: Utilization review evaluates the appropriateness of the types of services provided.

There are three types of utilization reviews: prospective, concurrent, and retrospective. Prospective utilization review is implemented before the service is actually performed by having the procedure authorized by the MCO, having the primary care provider decide to refer the member for the service, or assessing the service based on the clinical guidelines. Concurrent utilization reviews are decisions that are made during the actual course of service, such as length of inpatient stay and additional surgery.

Retrospective utilization review is an evaluation of services once the services have been provided. This may occur to assess treatment patterns of certain diseases. This type of review may include a financial review to assure accuracy of billing. Practice profiling, an offshoot of retrospective utilization review, examines specific provider patterns of practice. This is a type of employee performance review to determine which provider fits in with the organizational culture of the MCO. Complexity: Difficult Ahead: Cost-Control Measures of MCOs Subject: Chapter 9 Title: Managed Care Impact on Healthcare Delivery

2. Discuss the NCQA and how it evaluates managed care organizations.

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Basics of the U.S. Health Care System, Fourth Edition Nancy J. Niles

Ans: From a healthcare consumer perspective, when an organization’s top priority is cost control, there may be concerns about losing a level of quality. As managed care was integrated into Medicaid and Medicare, the government also became more involved in the evaluation of managed care providers. Also, as competition increased in the managed care arena, there was fear that more services would be reduced to maintain lower premiums. As a result of these issues, the National Committee on Quality Assurance (NCQA) was established in 1990 to maintain the quality of care in health plans.

The NCQA accredits MCOs and, although a voluntary review process, the process includes surveys completed by managed care experts and physicians. They evaluate access and service and quality of the MCO’s providers, primary prevention activities, and case management for the chronically ill. An organization can be accredited at three levels: excellent, commendable, or accredited. This accreditation, although voluntary, has alleviated concerns about the MCOs’ focus on cost control. There are 173 million enrollees in NCQA-accredited plans. The NCQA has developed a report card of accredited health plans that consumers can access on the NCQA’ s website. In the past, the NCQA had developed different criteria for the different types of MCOs. The NCQA developed standards and guidelines for all MCOs, regardless of their organizational structure. Since 2006, the NCQA has developed standards specifically for Medicaid Managed Care accreditation. There are currently 41 states that recognize the NCQA accreditation for both their Medicaid managed care and commercial managed care programs. Additionally, the NCQA has a physician directory that recognizes quality practices. As the MCO industry has become very competitive, it is to the benefit of an MCO to become accredited.

Complexity: Difficult Ahead: Assessment of Managed Care Models Subject: Chapter 9 Title: Managed Care Impact on Healthcare Delivery

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Chapter: Chapter 10 - Quiz

True/False

1. True or False? There is a product called Electronic Aspirin, which is an implant on the side of the head normally impacted by a headache.

Ans: True Complexity: Easy Ahead: History of IT in the Healthcare Industry Subject: Chapter 10 Title: Information Technology Impact on Health Care

2. True or False? Quality use, as defined by the CMS, has established core measures those healthcare providers must meet to determine the EHR system is being adequately used.

Ans: False Complexity: Moderate Ahead: Electronic Health Records (EHRs) Subject: Chapter 10 Title: Information Technology Impact on Health Care

3. True or False? Siemens has introduced a pocket-sized ultrasound, Acuson P10, which can be used for traditional applications of diagnostic and screening tests. It can be used in outpatient areas, intensive care units, and rescue helicopters to provide instant information to make a diagnosis.

Ans: True Complexity: Easy Ahead: Applied Health Information Technology Subject: Chapter 10 Title: Information Technology Impact on Health Care

4. True or False? Health information technology is important because it can reduce medical errors.

Ans: True Complexity: Moderate Ahead: The Importance of Health Information Technology Subject: Chapter 10

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Basics of the U.S. Health Care System, Fourth Edition Nancy J. Niles

Title: Information Technology Impact on Health Care

5. True or False? An example of telemedicine is electronic consulting between specialists and generalists.

Ans: True Complexity: Easy Ahead: Telehealth Subject: Chapter 10 Title: Information Technology Impact on Health Care

6. True or False? Information technology (IT) has had a tremendous impact on the healthcare industry because it allows faster documentation of every transaction.

Ans: True Complexity: Easy Ahead: Introduction Subject: Chapter 10 Title: Information Technology Impact on Health Care

7. True or False? The establishment of a chief information officer (CIO) in healthcare organizations emphasizes how important information systems and technology had become to healthcare organizations.

Ans: True Complexity: Easy Ahead: History of IT in the Healthcare Industry Subject: Chapter 10

8. True or False? Avera eCARE established eEmergency, which provides rural providers with immediate electronic access to emergency-certified physicians and nurses to help them with diagnosis of patients with critical conditions.

Ans: True Complexity: Easy Ahead: Telehealth Subject: Chapter 10 Title: Information Technology Impact on Health Care

Essay

1. Discuss the development of the program of “meaningful use” in EHRs and how it has impacted physician use.

Ans: In accordance with the HITECH Act, the Centers for Medicaid and Medicare Services (CMS) established incentives to encourage “meaningful use” of EHRs to increase patient care quality and safety.

Meaningful use, as defined by the CMS, has established core measures that healthcare providers must meet to determine the EHR system is being adequately used. Stage 1, defined in 2010, focused on patient data and medical history. Stage 2, effective in 2014, increased the physician use of computerized physician order entry and clinical decision support to improve patient health outcomes.

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Beginning in 2016, penalties were issued to providers that fail to meet the program’s requirements in the preceding year. Stage 3 objectives are focused on improving the interoperability of EHR systems in different practices. Prior to moving to Stage 3, the CMS established a “Modified Stage 2” (2015–2017), which combined the requirements of stages 1 and 2 for physicians. This modification was to reduce reporting requirements and assist with the transition to stage 3. Both healthcare professionals and hospitals are eligible for the program. They can participate in the Medicare, Medicare Advantage, or Medicaid program but cannot receive incentives for all of the programs. They must choose which program they wish to receive for the incentives.

Eligible healthcare professionals could participate for up to five continuous years and receive up to $44,000 for those years. Providers must demonstrate meaningful use on an annual basis. The last year for provider enrollment was 2014; however, to receive maximum participation, providers must have enrolled by 2012.

Effective 2015, providers who did not demonstrate meaningful use were subjected to a fine up to 5% of their incentive amount. Medicaid professionals can also be involved in the meaningful use of the EHR system. Nearly all states are administering the program. The federal government pays 90% of the state’s cost for implementing this type of electronic system. Medicaid incentives are higher than the Medicare program—up to $63,750 over 6 years. Physicians were financially penalized for not demonstrating meaningful use of EHRs each year. The payments for meaningful use to participants ceased 2018. As of 2011, over 400,000 physicians received payments under this program.

Complexity: Difficult Ahead; Electronic Health Records (EHRs) Subject: Chapter 10 Title: Information Technology Impact on Health Care

2. Identify five methods of telemedicine.

Ans: Primary care and specialist referral services may involve a primary care or allied health professional providing a consultation with a patient or a specialist assisting the primary care physician in rendering a diagnosis. This may involve the use of live interactive video or the use of stored and forwarded transmission of diagnostic images, vital signs, or video clips along with patient data for later review.

Remote patient monitoring, including home telehealth, uses devices to remotely collect and send data to a home health agency or a remote diagnostic testing facility (RDTF) for interpretation. Such applications might include a specific vital sign, such as blood glucose or heart ECG or a variety of indicators for homebound patients. Such services can be used to supplement the use of visiting nurses.

Consumer medical and health information includes the use of the Internet and wireless devices for consumers to obtain specialized health information and online discussion groups to provide peer-to-peer support.

Medical education provides continuing medical education credits for health professionals and special medical education seminars for targeted groups in remote locations.

Delivery mechanisms for telemedicine include the following: Networked programs link tertiary care hospitals and clinics with outlying clinics and community health centers in rural or suburban areas. The links may use dedicated high-speed lines or the Internet for telecommunication links between sites. The ATA estimates the number of existing telemedicine networks in the United States at roughly 200 providing connectivity to over 3000 sites.

Point-to-point connections, employing private high-speed networks, are used by hospitals and clinics that deliver services directly or outsource specialty services to independent medical service providers. Such outsourced services include radiology, stroke assessment, mental health, and intensive care services.

Monitoring center links are used for cardiac, pulmonary, or fetal monitoring; home care; and related services that provide care to patients in the home. Often, normal landline or wireless connections are used to communicate directly between the patient and the center, although some systems use the Internet.

Web-based e-health patient service sites provide direct consumer outreach and services over the Internet. Under telemedicine, these include those sites that provide direct patient care.

Complexity: Moderate Ahead; Telehealth Subject: Chapter 10

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Title: Information Technology Impact on Health Care

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Chapter: Chapter 11 - Quiz

True/False

1. True or False? According to the American Medical Association (AMA), once a patient and physician relationship has started, the physician is not legally but ethically obligated to continue the relationship until the patient no longer requires their care.

Ans: False Complexity: Easy Ahead: The Legal Relationship Between the Provider and Consumer Subject: Chapter 11 Title: Healthcare Law

2. True or False? The Sherman Act of 1890 focuses on eliminating monopolies, which are healthcare organizations that control a market so that the consumer has no choice in health care.

Ans: True Complexity: Easy Ahead: Healthcare-Related Legislation Subject: Chapter 11 Title: Healthcare Law

3. True or False? An affirmative action plan is a strategy that encourages employers to increase the diversity of their workforce by hiring individuals based on race, sex, and age.

Ans: True Complexity: Easy Ahead: Employment-Related Legislation Subject: Chapter 11 Title: Healthcare Law

4. True or False? The Occupational Health and Safety Act was passed to ensure that employers have a duty to treat to provide a safe and healthy work environment for their employees, which are very important for the healthcare industry because of potential exposure to bacteria, viruses, and contaminated fluids.

Ans: False

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Complexity: Moderate Ahead: Employment-Related Legislation Subject: Chapter 11 Title: Healthcare Law

5. True or False? Economic equipment and actions are important to the healthcare industry because many workers often lift patients to and from beds, operating tables, and wheelchairs.

Ans: False Complexity: Moderate Ahead: Employment-Related Legislation Subject: Chapter 11 Title: Healthcare Law

6. True or False? The Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA), an amendment to ERISA, was passed to protect employees who lost or changed employers so they could keep their health insurance if they paid 102% of the full premium.

Ans: True Complexity: Easy Ahead: Other Employment-Related Legislation Subject: Chapter 11 Title: Healthcare Law

7. True or False? The Lilly Ledbetter Fair Pay Act of 2009 (FPA), an amendment to Title VII of the Civil Rights Act of 1964, which also applies to claims under the Age Discrimination Act of 1967 and the Americans with Disabilities Act of 1990, provides protection for unlawful employment practices related to compensation discrimination.

Ans: True Complexity: Easy Ahead: Other Employment-Related Legislation Subject: Chapter 11 Title: Healthcare Law

8. True or False? The Genetic Information Nondiscrimination Act of 2008 prohibits U.S. insurance companies and employers from discriminating based on information derived from genetic tests.

Ans: True Complexity: Easy Ahead: Other Employment-Related Legislation Subject: Chapter 11 Title: Healthcare Law

9. True or False? Failing to hire an applicant because she is a transgender woman and firing an employee because she or he is planning or has made a gender transition are considered unlawful sex discrimination according to the Equal Employee Opportunity Commission (EEOC).

Ans: True Complexity: Easy Ahead: Employment-Related Legislation

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Subject: Chapter 11 Title: Healthcare Law

Essay

1. Discuss the appropriate way for a physician to end a relationship with a patient.

Ans: According to the American Medical Association (AMA), once a patient and physician relationship has started, the physician is legally and ethically obligated to continue the relationship until the patient no longer requires the physician’s care. There may be a practical reason for a relationship to end, such as geographic relocation or change of healthcare insurance. If a patient becomes noncompliant and abusive, the physician has the right to end a relationship. However, to protect the physician from being accused of “patient abandonment,” the physician must take steps to properly end the relationship. If a patient withdraws from the relationship with the provider, then the physician no longer has a duty to provide follow-up. Also, if medical care is no longer needed, the relationship naturally is completed. If a patient is transferred to another provider, the provider then establishes a relationship with the new patient.

However, a physician could withdraw from a relationship by giving sufficient notice or providing the patient with a referral. However, if a physician withdraws from a relationship without sufficient reason, the provider may be liable for breach of contract or patient abandonment. The AMA provides the following five steps for a physician to terminate a relationship: 1. Giving the patient written notice, preferably by certified mail 2. Providing the patient with a specific reason for termination 3. Continuing to provide care for a reasonable period of time, so that the patient can find other care 4. Providing assistance to the patient to find other care 5. Offering to transfer all medical records with the patient’s permission Complexity: Difficult Ahead: The Legal Relationship Between the Provider and Consumer Subject: Chapter 11 Title: Healthcare Law

2. What is the purpose of antitrust laws? How do they impact patients?

Ans: The purpose of the antitrust law is to protect the consumer by ensuring that there is a market driven by competition, so that the consumer has a choice for health care. In a sense, antitrust laws protect competition, so that the consumer has a choice. Antitrust laws apply to most healthcare organizations.

There are both federal and state antitrust laws. There are four main antitrust federal laws that will be discussed in this chapter: the Sherman Antitrust Act, the Clayton Act, the Federal Trade Commission Act, and the Robinson-Patman Act (the amendment to the Clayton Act). These acts are important to know because they were developed to ultimately protect the healthcare consumer and those who provide healthcare services.

The Sherman Act of 1890 focuses on eliminating monopolies, which are healthcare organizations that control a market, so that the consumer has no choice in health care. It also targets price fixing among competitors; price fixing prevents consumers from paying a fair price because competitors establish a certain price (by either increasing or lowering prices) among themselves to stabilize the market.

Healthcare facilities may also have an agreement on market division. This illegal action occurs when one or more health organizations decide which type of services will be offered at each organization. Tying refers to healthcare providers that will only sell a product to a consumer who will also buy a second product from them. Boycotts are also illegal according to this act. When healthcare providers have an agreement to not deal with anyone outside their group, that is considered interfering with the consumers’ rights to choose. Price information exchange of services between providers can also be illegal.

Healthcare providers are protected under the act if it has been determined that hospitals have exclusive contracts with certain providers, which excludes other providers from use of the hospital. This could be a

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violation of the act. Violations of the act are considered federal crimes.

Complexity: Difficult Ahead: Healthcare-Related Legislation Subject: Chapter 11 Title: Healthcare Law

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Chapter: Chapter 12 - Quiz

True/False

1. True or False? Transplantation is the general procedure of implanting a functional organ from one person to another.

Ans: True Complexity: Easy Ahead: Bioethical Issues Subject: Chapter 12 Title: Healthcare Ethics

2. True or False? Xenotransplantation is the general procedure of implanting a functional organ from one person to another.

Ans: False Complexity: Moderate Ahead: Bioethical Issues Subject: Chapter 12 Title: Healthcare Ethics

3. True or False? Xenotransplantation evolved as a result of the shortage of human organs available for donation. The first operation of this type was the transfer of a baboon heart into a 5 pound infant in 1984.

Ans: True Complexity: Easy Ahead: Bioethical Issues Subject: Chapter 12 Title: Healthcare Ethics

4. True or False? The priestly model assumes the doctor will make the best decisions for the patient’s health. The patient assumes a very passive role, giving the provider great power in the decision-making process. This is a very traditional relationship that often would occur between the elderly and physicians because they were taught to revere the medical world.

Ans: True Complexity: Easy

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Ahead: Physician–Patient Relationship Model Subject: Chapter 12 Title: Healthcare Ethics

5. True or False? The servant leadership model assumes the doctor will make the best decisions for the patient’s health. The patient assumes a very passive role, giving the provider great power in the decisionmaking process. This is a very traditional relationship that often would occur between the elderly and physicians because they were taught to revere the medical world.

Ans: False Complexity: Moderate Ahead: Physician–Patient Relationship Model Subject: Chapter 12 Title: Healthcare Ethics

6. True or False? Autonomy, which is defined as self-rule, is an important concept to health care because it is applied to “informed consent,” which requires a provider to obtain the approval of a patient who has been provided adequate information to make a decision regarding intervention.

Ans: True Complexity: Easy Ahead: Physician–Patient Relationship Model Subject: Chapter 12 Title: Healthcare Ethics

7. True or False? Physician-assisted suicide refers to the physician injecting a lethal dose of a drug into the patient at their request.

Ans: False Complexity: Moderate Ahead: Bioethical Issues Subject: Chapter 12 Title: Healthcare Ethics

Short Answer

1. __________ is a group that has been formally designated to review and monitor biomedical research involving human subjects.

Ans: Institutional Review Boards Complexity: Easy Ahead: Ethics and Research Subject: Chapter 12 Title: Healthcare Ethics

2. All human beings possess __________, which are “starter” cells for the development of body tissue that have yet to be formed into specialized tissues for certain parts of the body.

Ans: stem cells

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Complexity: Easy Ahead: Bioethical Issues Subject: Chapter 12 Title: Healthcare Ethics

3. In other parts of the world, countries use __________, which means that if a parent does not actively oppose the transplantation, the procedure automatically occurs.

Ans: presumed consent Complexity: Easy Ahead: Bioethical Issues Subject: Chapter 12 Title: Healthcare Ethics

Essay

1. Identify strategies to prevent workplace bullying.

Ans: To reduce the prevalence of workplace bullying, it is important that employers implement policies to eliminate this behavior. The American Psychological Association has provided recommendations on how to stop office bullying: 1.

Improve communication skills among employees. The Veterans Affairs implemented a pilot program called Collaborative Inquiry, which encourages employee groups to assess a problem through data collection and then decide how to solve the problem through reflection and action.

The groups that were trained in this method reported less aggression and more satisfaction with their work environment.

2.

Teach employees how to understand each other. Small groups of workers assess how they perceive violent behaviors in the workplace. For example, someone kicking a wall or throwing something may make someone feel better but scare someone else. These types of exercises helped people consider other people’s perspectives and develop healthy ways to relieve stress.

3.

Identify root causes of anger and frustration. Employees at one organization felt there was favoritism among certain employees, and others felt their concerns were not being heard by management. After implementing an employee survey, management randomly selected employees to attend meetings to hear their concerns. Follow-up surveys indicated there were less bullying and aggressive behavior.

4.

Establish a workplace policy of respect. Include a antibullying policy with an enforcement policy in the employee manual, and implement employee training at all employment levels to address this issue.

Complexity: Difficult Ahead: Workplace Bullying Subject: Chapter 12 Title: Healthcare Ethics

2. Identify an ethical issue in healthcare. Identify the steps in an ethical decision-making model and apply these steps to your identified ethical issues.

Ans: Healthcare dilemmas require guidelines to process a solution to the dilemma. Codes of ethics and HR training can assist with a solution. Employee training can include a decision-making model that will assist the individual to process the steps in resolving the situation. The PLUS ethical decisionmaking model consists of the following: 1.

Identification of the dilemma.

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2.

Identification of the conflicting ethics of each party.

3.

Identification of alternatives to a solution.

4.

Identification of the impact of each alternative.

5.

Selection of the solution.

Complexity: Difficult Ahead: Ethical Decision-Making Model Subject: Chapter 12 Title: Healthcare Ethics

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Chapter: Chapter 13 - Quiz

Multiple Choice

1. When a behavioral specialist uses video conferencing to manage and assist with the treatment of a mentally ill patient, it is called: A) apple behavioral consulting.

B) telemarketing mental issues.

C) telebehavioral health.

D) an information technology consult.

Ans: C Complexity: Easy Ahead: Mental Health and Culture, Race, and Ethnicity Subject: Chapter 13 Title: Mental Health Issues

2. The National Institute for Mental Health’s strategic plans includes which of these core areas of focus?

A) Research causes of mental health disorders.

B) Chart mental health disorders to determine treatment.

C) Improve interventions.

D) All of these are correct.

Ans: D Complexity: Easy Ahead: National Institute for Mental Health Strategic Plan Subject: Chapter 13 Title: Mental Health Issues

3. Which of the following are part of the de facto mental health service system in the United States?

A) Home (family) B) Community (nonprofit organizations) C Healthcare providers D) All of these are correct.

Ans: D Complexity: Moderate Ahead: Background of Mental Health Services

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Subject: Chapter 13 Title: Mental Health Issues

4. What is the purpose of the Mental Health Parity Act and its amendment?

A) Requires the same mental health coverage by health insurance companies as traditional medical care coverage.

B) Requires full disclosure of health plan coverage of mental health care.

C) Requires that intermediate levels of mental health of coverage include residential treatment and outpatient care.

D) All of these are correct.

Ans: D Complexity: Difficult Ahead: Background of Mental Health Services Subject: Chapter 13 Title: Mental Health Issues

True/False

1. True or False? Ayurveda medicine incorporates diet, meditation, herbal medicine, and nutrition to treat depression and to release stress.

Ans: True Complexity: Easy Ahead: Alternative Approaches to Mental Health Care Subject: Chapter 13 Title: Mental Health Issues

2. True or False? Acupuncture medicine incorporates diet, meditation, herbal medicine, and nutrition to treat depression and to release stress.

Ans: False Complexity: Moderate Ahead: Alternative Approaches to Mental Health Care Subject: Chapter 13 Title: Mental Health Issues

3. True or False? Psychologists, who also participate in the treatment of mental health, cannot prescribe drugs but provide different types of therapy.

Ans: True Complexity: Easy Ahead: Background of Mental Health Services Subject: Chapter 13 Title: Mental Health Issues

4. True or False? Psychiatrists, who also participate in the treatment of mental health, cannot prescribe drugs but provide different types of therapy.

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Ans: False Complexity: Moderate Ahead: Background of Mental Health Services Subject: Chapter 13 Title: Mental Health Issues

5. True or False? Alzheimer’s disease causes the death of brain cells that control memory.

Ans: True Complexity: Easy Ahead: Special Populations Subject: Chapter 13 Title: Mental Health Issues

6. True or False? Pseudo dementias may develop as a result of medications, drug interactions, and poor diet, or heart and gland diseases. These dementias may occur accidentally because of these conditions.

Ans: True Complexity: Easy Ahead: Special Populations Subject: Chapter 13 Title: Mental Health Issues

7. True or False? Only 15% of the elderly population suffers from dementia.

Ans: True Complexity: Easy Ahead: Special Populations Subject: Chapter 13 Title: Mental Health Issues

Essay

1. Identify strategies for caregivers to ensure they are taking care of themselves when they are caring for a family member.

Ans: As with any chronic condition, family members and caregivers are often impacted by caring for afflicted individuals. Caregivers are unpaid individuals who are often involved in providing assistance with the activities of daily living (ADLs). There are approximately 44 million caregivers in the United States.

The majority of them care for one adult. Approximately 40 million caregivers provide care to adults with a disability or illness. They often do not think of themselves as needing any attention because their focus is on the afflicted family member. It is important to take some personal time out of the “caregiver mode” to take care of and reflect on the emotional needs of the caregiver. The following is some advice for caregivers on taking care of themselves: 1.

Support groups: Caregivers may feel guilty if they resent their role as a caregiver. Do not judge your thoughts as bad, which will increase your stress; instead, recognize that other people may have the same feelings. Going to support groups to discuss your feelings provides an opportunity to deal with these issues.

2.

Do not ignore personal relationships: Caregivers may unintentionally lose contact with friends.

Set up times, even if only once per month, to see friends for a short period of time. These

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personal times provide an opportunity to step away from the caregiver mode.

It is very difficult to take care of someone else if the caregiver does not take care of himself or herself first.

Complexity: Moderate Ahead: Family and Caregivers Subject: Chapter 13 Title: Mental Health Issues 3.

2. Discuss the new B4Stage4 mental health model.

Ans: Mental Health America has developed a proactive philosophy to treat mental health like other diseases, such as cancer and diabetes. With cancer and other chronic diseases, the medical community recognizes early symptoms and hopes to treat them before they progress to stage 4, which is typically the end stage of a disease. Mental Health America is proposing to apply the same philosophy to recognize early signs of mental illness and treat them before it progresses to a more serious mental health illness.

The focus is early identification and intervention.

Stage 1: Mild Symptoms and Warning Signs. At Stage 1, a person begins to show symptoms of a mental health condition but is still able to maintain the ability to function at home, work, or school— although perhaps not as easily as before they started to show symptoms. Often, there is a sense that something is “not right.”

Stage 2: Symptoms Increase in Frequency and Severity and Interfere with Life Activities and Roles. At Stage 2, it usually becomes obvious that something is wrong. A person’s symptoms may become stronger and last longer or new symptoms may start appearing on top of existing ones, creating something of a snowball effect. Performance at work or school will become more difficult, and a person may have trouble keeping up with family duties, social obligations, or personal responsibilities.

Stage 3: Symptoms Worsen with Relapsing and Recurring Episodes Accompanied by Serious Disruption in Life Activities and Roles. At Stage 3, symptoms have continued to increase in severity, and many symptoms are often taking place at the same time. A person may feel as though they are losing control of their life and the ability to fulfill their roles at home, work, or school.

Stage 4: Symptoms Are Persistent and Severe and Have Jeopardized One's Life. By Stage 4, the combination of extreme, prolonged, and persistent symptoms and impairment often results in development of other health conditions and has the potential to turn into a crisis event like unemployment, hospitalization, homelessness, or even incarceration. In the worst cases, untreated mental illnesses can lead to loss of life an average of 25 years early.

Complexity: Moderate Ahead: B4Stage4 Subject: Chapter 13 Title: Mental Health Issues

3. Discuss mental health issues and the homeless population. Provide statistics regarding mental health care and the homeless.

Ans: Approximately 3.5 million people in the United States experience homelessness each year. Over 33% of the homeless are families with children, which is the fastest-growing segment. Approximately 25% of the homeless population has mental health issues such as personality disorders. The health status of the homeless is overall poor because of lack of housing. They are exposed to more disease and do not have adequate access to health care thus their health status deteriorates over time. Mental health and substance abuse problems are common in the homeless population. As a result of their lack of stability, it is difficult to provide adequate mental health care.

Complexity: Difficult Ahead: Mental Health and Culture, Race, and Ethnicity Subject: Chapter 13 Title: Mental Health Issues

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4. Discuss mental health issues with the military.

Ans: With nearly 155 hospitals serving about 8 million war veterans and current servicemen, the VA operates the largest healthcare system and is the largest single employer of psychologists in the country.

In 1989, the National Center for Posttraumatic Stress Disorder was created within the VA to address the needs of the military-related PTSD. Current statistics indicate that the suicide rate for male veterans 18– 29 years of age rose 26% from 2005 to 2007 with record rates in 2009. Of the 1.7 million veterans returning from Afghanistan and Iraq, 20% suffer from posttraumatic stress disorder or major depression.

Mental health issues are the leading cause of hospitalizations for active duty military. According to recent research, military suicides are the result of untreated mental illnesses. Many veterans seek help outside the VA healthcare system. Their reasons for not seeking help were because of the fear of being stigmatized for seeking these types of service. The Army, which has a longtime policy of requiring the commanding officer to be notified if a soldier voluntarily seeks counseling, is seeking to suspend this rule.

This fear of stigmatization is similar in the general population. There are new military healthcare models to ensure that mental health services are being offered confidentially.

Complexity: Moderate Ahead: Mental Health and Veterans Subject: Chapter 13 Title: Mental Health Issues

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Chapter: Chapter 14 - Quiz

Multiple Choice

1. What is the purpose of a care coordinator/patient navigator?

A) Individuals who combine nursing, social work, and disability assistance to help those who are Medicare and Medicaid eligible and suffer from chronic conditions.

B) Individuals who coordinate care for homeless people with mental health disorders.

C) Individuals who coordinate care for those children with terminal illnesses.

D) Individuals who coordinate care for those patients with no health insurance.

Ans: A Complexity: Easy Ahead: Trends in Healthcare Subject: Chapter 14 Title: Analysis of the U.S. Healthcare System

2. Which statement is true about France’s health insurance system?

A) All physicians participate in their public health insurance.

B) Physicians are able to charge more because there is no competition.

C) Physicians pay more malpractice premiums than U.S. doctors.

D) Payroll taxes provide the least amount of funding for their healthcare system.

Ans: A Complexity: Easy Ahead: Universal Healthcare Concepts Subject: Chapter 14 Title: Analysis of the U.S. Healthcare System

3. Which statement is correct about Switzerland’s healthcare system?

A) Approximately 99.5% of Swiss citizens have health insurance.

B) Healthier citizens pay more for their healthcare insurance.

C) Nonsmokers pay less expensive premiums than smokers.

D) All of these are correct.

Ans: D Complexity: Easy Ahead: Universal Healthcare Concepts Subject: Chapter 14

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Title: Analysis of the U.S. Healthcare System

4. Which statement is correct about Japan’s healthcare system?

A) Japan is very focused on integrating technology into their healthcare system.

B) Japan’s healthcare system is based largely on an employer based insurance.

C) Both Japan is very focused on integrating technology into their healthcare system and Japan’s healthcare system is based largely on an employer based insurance.

D) None of these are correct.

Ans: C Complexity: Difficult Ahead: Universal Healthcare Concepts Subject: Chapter 14 Title: Analysis of the U.S. Healthcare System

True/False

1. True or False? National health insurance, as in Canada, is funded by the government through general taxes although the delivery of care is by private providers. Countries with national healthcare programs provide universal access to health care to all citizens.

Ans: True Complexity: Easy Ahead: Universal Healthcare Concepts Subject: Chapter 14 Title: Analysis of the U.S. Healthcare System

2. True or False? In a national health system, as in Great Britain, taxes support the system but the government also manages the infrastructure for healthcare delivery. Countries with national healthcare programs provide universal access to health care to all citizens.

Ans: True Complexity: Easy Ahead: Universal Healthcare Concepts Subject: Chapter 14 Title: Analysis of the U.S. Healthcare System

3. True or False? Pay for performance (P4P) and value-based purchasing (VBP) are terms that describe healthcare payment systems that reward healthcare providers for their efficiency by providing higherquality care for less cost.

Ans: True Complexity: Easy Ahead: Trends in Healthcare Subject: Chapter 14 Title: Analysis of the U.S. Healthcare System

4. True or False? Legal standards are the maximum standard of action established for individuals in a

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society.

Ans: False Complexity: Moderate Ahead: Healthcare Ethics Subject: Chapter 14 Title: Analysis of the U.S. Healthcare System

5. True or False? Legal standards are the minimum standard of action established for individuals in a society.

Ans: True Complexity: Easy Ahead: Healthcare Ethics Subject: Chapter 14 Title: Analysis of the U.S. Healthcare System

6. True or False? The Villages is one of the largest over-55 golf cart communities in the United States.

They have developed a partnership with the University of South Florida to create a patient-centered, community-based and primary care driven healthcare system. A primary care network is being developed in which all residents have access to a medical home or care center that will be located within 10 minutes by golf cart.

Ans: True Complexity: Easy Ahead: Trends in Healthcare Subject: Chapter 14 Title: Analysis of the U.S. Healthcare System

7. True or False? In France, consumers historically have had no restrictions on physician selection. They may visit several physicians before they find a physician they prefer. This type of medical drives up health care costs.

Ans: True Complexity: Easy Ahead: Universal Healthcare Concepts Subject: Chapter 14 Title: Analysis of the U.S. Healthcare System

8. True or False? Cultural health awareness is the ability to identify personal cultural assumptions and be open to unfamiliar cultures.

Ans: False Complexity: Moderate Ahead: Cultural Competency Subject: Chapter 14 Title: Analysis of the U.S. Healthcare System

9. True or False? Cultural competency is the ability to successfully delivery healthcare services to satisfy diverse populations’ cultural and linguistic needs.

Ans: False

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Complexity: Moderate Ahead: Cultural Competency Subject; Chapter 14 Title: Analysis of the U.S. Healthcare System

10. True or False? mHealth is the use of smartphones and other mobile devices to access healthcare information and track healthy activities.

Ans: True Complexity: Easy Ahead: Trends in Health Care Subject: Chapter 14 Title: Analysis of the U.S. Healthcare System

11. True or False? An important activity of telehealth is the use of email communication between providers and patients.

Ans: True Complexity; Easy Ahead: Telehealth Subject: Chapter 14 Title: Analysis of the U.S. Healthcare System

12. Complementary medicine combines a combination of alternative and traditional medicine in treating a patient.

Ans: False Complexity: Moderate Ahead: Trends in Healthcare Subject: Chapter 14 Title: Analysis of the U.S. Healthcare System

13. Common law is created by legislative bodies.

Answer: False court system Complexity: Moderate Ahead; Healthcare Law Subject: Chapter 14 Title: Analysis of the U.S. Healthcare System

Essay

1. Discuss the concepts of universal health care. Do you agree or disagree with this type of system?

Ans: Countries with national healthcare programs provide universal access to health care to all citizens.

They have a single-payer system, which means the government pays for the healthcare services. There are three models for structuring a universal or national healthcare system: national health insurance, national health system, and socialized health insurance system. National health insurance, as in Canada, is funded by the government through general taxes, although the delivery of care is by private providers.

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Basics of the U.S. Health Care System, Fourth Edition Nancy J. Niles

In a national health system, as in Great Britain, taxes support the system but the government also manages the infrastructure for healthcare delivery. In a socialized health insurance system, as in Germany, the government mandates financial contributions by both employers and employees, with private providers delivering health care. Sickness funds, which are nonprofit insurance companies, collect the contributions and pay the healthcare providers. The U.S. healthcare system is employer–employee based and government funded. The U.S. system provides 100% coverage for people 65 years of age or older with the Medicare program, and 82% coverage for people younger than 65 years of age through employer-based insurance, Medicaid, IHS, Veterans’ Administration (TRICARE), and the federal government employee program.

Complexity: Difficult Ahead: Universal Healthcare Concepts Subject: Chapter 14 Title: Analysis of the U.S. Healthcare System

2. Select one of the countries discussed in the chapter. Which of the country’s system do you think could be applied to the US? Defend your answer.

Ans: Japan: The system is regulated by the Japanese government with the statutory goal of providing quality care. The country’s life expectancy in 2016 was one of the best in the world—83.7 years of age.

Statutory Health Insurance System (SHIS) has 3400 insurers. Japan’s health expenditures represent 11% of GDP. Approximately 15% of hospitals are government-owned. Based on age, employment status and place of residence, citizens and non-citizen residents must enroll in one of the SHISs. All of the SHIS plans provide the same benefits. Those over 40 years of age are automatically enrolled in long-term care insurance. As part of the Japanese health insurance system, the insured pays a premium to the health insurance companies, and in case of a care visit, the insured pays a 30% coinsurance rate to the healthcare institutions. The majority of medical facilities are privately owned. Medical fees are controlled by the government. There are more than 4,000 community comprehensive support centers to coordinate services for chronic diseases. The Social Security and Tax Number System (SSTNS), a system of unique identifiers, was started in 2016 and is designed to be used as an identifier to medical services for citizens. Under the 2015 Health Care Reform Act, local governments will be responsible for administering community-based plans and setting and collecting insurance premiums. Large hospitals will also be required to promote care coordination with community providers.

With a rapidly aging population with increasing chronic diseases, it is estimated that spending will continue to rise. Japan has the highest number of MRI and CT machines, long hospital stays, and more outpatient services compared to the United States. The access to their healthcare system is patient friendly, which creates overuse of their services, increasing the government’s healthcare costs. The system focuses on specialists, rather than primary care providers, who have less training, which results in less focus on primary prevention of disease.

France: France’s healthcare system has many characteristics of a socialized health insurance program similar to Germany and Japan. It has often been touted as one of the best healthcare systems in the world. The system consists of statutory health insurance (SHI), funded by payroll taxes (50%), a national income tax (35%), alcohol and tobacco taxes, the drug industry, and voluntary health insurance companies (13%), and state subsidies (2%). There is universal coverage for approximately 99% of French citizens. The state has become increasingly involved in controlling health expenditures, which represent 12% of GDP. Cost sharing comes from coinsurance and copayments. The SHI has faced tremendous deficits over the last 20 years, but the deficit has decreased dramatically as a result of country-wide initiatives. The initiatives include a reduction in the number of hospitals, the removal of 600 medications from public reimbursement, an increase in generic-drug prescribing, and the increased use of over-the-counter medications. France also has focused on cost containment through central purchasing.

Unlike the United States, the French government makes it very difficult for insurance companies to deny any coverage because of preexisting conditions. Citizens who are very ill receive increased care and coverage, which is unlike the U.S. system, in which individuals may go financially bankrupt because of their cost sharing during a chronic disease.

All physicians in France participate in the nation’s public health insurance (like Medicaid). The average

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Basics of the U.S. Health Care System, Fourth Edition Nancy J. Niles

American physician earns more than five times the average U.S. wage, whereas the average French physician makes only about two times the average French wage. However, in France, medical schools, although extremely competitive to enter, are tuition free. Therefore, French physicians enter their careers with minimal debt. Unlike U.S. physicians who pay high malpractice premiums, they pay much lower malpractice insurance premiums because lawsuits against physicians are much less common in France. French physicians have fewer administrative expenses because the government has created a standardized, efficient system for physician billing and patient reimbursement using electronic funds. It is interesting to note that the French government allows physicians to charge more than the government’s reimbursement schedule, although physicians employed by hospitals are not allowed to set their own fees. Most physicians do not overcharge because of the intense competition in their field. Primary health care is provided by a network of general practitioners. Nearly all general practitioners sign a contract with the government, indicating they will provide services at the national rates. Specialists also agree with providing care for established national rates.

Consumers have had no restrictions on physician selection; they may visit several physicians before they find the one they prefer. This type of medical nomadism drives up healthcare costs. In response to this issue, in 2005, the government established a coordinated care pathway, which is similar to the U.S. managed care system. Individuals are encouraged to choose a preferred doctor and follow the doctor’s pathway for their care. There is a financial incentive for registering with a general practitioner or specialist. At this point, this is a choice, not a mandate; however, individuals’ cost sharing does increase if they refuse to purchase generic drugs and do not use the coordinated care pathway system.

There were two health reforms in 2016 to target health disparities in the country by providing universal access to the statutory insurance and a third-party plan for physician consults, which is being implemented in stages.

Switzerland: Switzerland’s healthcare system is considered one of the best in the world, like that of the United States. It is unique because all residents are required to purchase health insurance, so, in a sense, it is a country with universal healthcare coverage. Approximately 99.5% of Swiss have health insurance paid for by mandatory SHI premiums. Health spending is 11% of GDP. Individuals buy insurance directly from private insurance providers. The Swiss system is similar to the “managed competition” healthcare plan proposed by Bill and Hillary Clinton in the early 1990s. Swiss law requires all citizens to purchase a health insurance package. Insurers cannot reject an applicant based on his or her health status. Healthier consumers pay higher premiums to subsidize the costs for the less healthy.

Nonsmokers pay lower premiums than smokers. Insurers compete on price. Consumers, however, can adjust their premium up or down by choosing a larger or smaller annual deductible or by joining a managed care plan. Switzerland ranks second only to the United States in the ability of patients to choose their provider.

Physicians are required to meet educational standards, and continuing education is mandatory. Unlike in the other countries discussed in this chapter, few Swiss employers provide insurance or contribute to insurance, so individuals bear the full cost of insurance plans. The government subsidizes the indigent.

The Swiss healthcare insurance industry is private but regulated by the government. Swiss citizens pay more for health insurance than do citizens of other European countries. The government controls prescription medication prices, of which consumers pay 10%. Like the United States and Japan, Switzerland has focused on health technology. A national e-health service called eHealth Suisse is coordinated by the government. All providers must collect and store patient information electronically, and any health-related websites where the information is collected must be quality certified. Every citizen has an SHI subscription card, which has an encoded personal identification number that allows medical information to be coded on the card if the insurer agrees. Increasing quality of care is a government priority for Health2020, which includes a network for quality programs, such as drug safety and reducing hospital infections.

Complexity: Difficult Ahead: Universal Healthcare Concepts Subject: Chapter 14 Title: Analysis of the U.S. Healthcare System

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