Retrospective Pay v. Prospective Pay & Define DRGs - ANSWER*Retrospective*:
- paid all bills sent to them without looking at them until they were already paid
- paid for unnecessary charges & doctor's errors
- hospitals were reimbursed for all costs
*Prospective*:
- payment for hospital ser...
Retrospective Pay v. Prospective Pay & Define DRGs - ANSWER*Retrospective*:
- paid all bills sent to them without looking at them until they were already paid
- paid for unnecessary charges & doctor's errors
- hospitals were reimbursed for all costs
*Prospective*:
- payment for hospital services to Medicare pts was based on a flat fee per admission based on the
Diagnostic Related Groups (DRGs)
- "you can bill us for this service but we have a flat fee per service and we won't pay anything over
that"
*Diagnosis Related Groups (DRGs)*: decides what the hospital will be paid based on diagnosis
Private & Other Healthcare Systems - ANSWER- charges are negotiated in advance of the delivery of
care using predetermined reimbursement rates or capitation fees for medical care, hospitalization or
other health care services
*HMO's (Health Maintenance Organizations)*:
- will pay for a certain physician & there will be a capitation
*PPO's (Preferred Provider Organization)*:
- if you go to one of their preferred provider's you get a discount (capitation)
- you might only have to pay a copay; it depends on how the plan is written
What are the factors influencing the changes in Healthcare? - ANSWER- Socioeconomic
Considerations
- Changing Demographics
- *Nature & Prevalence of Illness* (main one highlighted on slide)
, - Technology
Key Points for Changing Demographics - ANSWER(not on slides but on study guide)
- Elderly population increasing more rapidly
- More demands on healthcare system (changing the overall healthcare needs R/T change in
population)
- More medical & social issues:
- multiple chronic medical conditions
- physical & functional disabilities
- dementia
- fixed incomes
- limited family & community support
Key Points for Nature & Prevalence of Illness - ANSWER*expanded life expectancy* + *lifestyle issues
in our country* = *increase in the number, severity & duration* of chronic health conditions
- *chronic diseases* are responsible for *70% of all deaths in the US*:
- CV disease, obesity, cancer, diabetes, chronic lung disease (COPD); *many of these are related to
lifestyle behaviors*
Fcous of today's healthcare is shifting from intervention in the acute phases of disease toward what?
- ANSWER- early screening, detection & prevention
- nursing practice should focus on promotion of regular screenings, teaching of positive health
behaviors & assisting patients/families to manage chronic illness at home
Key Points for Socioeconomic Considerations - ANSWER(not on slides but on study guide)
- changes in healthcare have been largely initiated by the continued efforts of the government,
employers, insurance companies & regulating agencies to provide healthcare in the most cost-
effective manner
What are the 3 types of prevention of prevalence of illness? - ANSWER1) *Primary*: focuses on
health promotion & prevention of illness and disease, including interventions such as *teaching
about healthy lifestyles*
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