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

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

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. An older adult patient was admitted to the hospital and his condition was classified as “pneumonia”; reimbursement was based on a predetermined fixed price. This classification system is referred to as
A.
diagnosis-related groups (DRGs).
B.
subjective symptom management.
C.
acuity classification system.
D.
organized managed care.

ANS: A
Choice (A) is correct because diagnosis-related groups (DRGs) are used in reimbursement for health care services that is based on a predetermined fixed price per case or diagnosis in 468 categories. Under DRGs, each Medicare patient is assigned to a diagnostic grouping on the basis of his/her primary diagnosis at hospital admission. Medicare limits total payment to the hospital to the amount preestablished for that DRG. (B), (C), and (D) are incorrect because these are not reimbursement types that are based on predetermined pricing.

DIF: Comprehension REF: Page 127

2. The precise classification of patients according to the highest DRG has created a new role for nurses, referred to as
A.
case management nurse.
B.
quality assurance nurse.
C.
utilization review nurse.
D.
cost-control nurse.

ANS: C
Choice (C) is correct because hospital-based utilization review nurses review medical records to determine the most appropriate DRG for patients. Financial gains can be made through careful diagnosis of patients according to their highest potential DRG classification. (A) is incorrect because a case management nurse coordinates the patient’s care throughout the course of an illness. Case managers generally do not perform direct care duties but assume a planning and evaluation role and collaborate with the interdisciplinary health care team to ensure that goals are met, quality is maintained, and progress toward discharge is made. (B) is incorrect because the quality assurance nurse facilitates patient care delivery through quality monitoring and quality improvement initiatives. (D) is incorrect because a cost-control nurse is not a standard role in hospitals.

DIF: Knowledge REF: Page 127

3. Diagnosis-related groups (DRGs) have attempted to reduce health care costs by decreasing
A.
hospital admission rates.
B.
length of hospital stay.
C.
outpatient services.
D.
specialty groups.

ANS: B
Choice (B) is correct because hospitals face a strong financial incentive from the DRG reimbursement system to reduce the patient’s length of stay and minimize procedures performed. If hospital costs exceed the DRG payment for a patient’s treatment, the hospital incurs a loss, but if costs are less than the DRG amount, the hospital makes a profit. (A) is incorrect because decreasing hospital admission rates has not been shown to reduce the costs of health care. (C) is incorrect because decreasing outpatient services would actually drive costs up because more services would have to be performed as in-patient procedures. (D) is incorrect because decreasing specialty groups would not affect hospital reimbursement, which is the focus of the DRG payment system.

DIF: Application REF: Page 127

4. When reviewing the literature on the effects of Medicaid on health care for the poor, the nurse researcher found that the poor
A.
have less access than even the uninsured.
B.
receive many unnecessary treatments.
C.
lack consistent providers.
D.
abuse preventive services.

ANS: C
Choice (C) is correct because the poor are more likely to lack a usual source of care, are less likely to use preventive services, and are more likely to be hospitalized for avoidable conditions than are those who are not poor. (A) is incorrect because both the poor and uninsured may have limited transportation, limiting their access to health care facilities. (B) is incorrect because the poor generally receive very few treatments because of lack of payment to the provider or facility. (D) is incorrect because the poor rarely seek preventive services, which explains why their overall health status is lower.

DIF: Comprehension REF: Page 128