Economic Influences

1. A nurse is discussing how health care rationing occurs in the United States. Which of the following would most likely be discussed as the criterion that is used to ration health care?

a.
Clinic operating hours
b.
Ability to pay for services
c.
Availability of local provider services
d.
Transportation availability

ANS: B

Because there are not enough health care services available to provide desired services to everyone, the focus has been on reducing costs by controlling the use of services. All of the factors listed affect health care access and therefore affect health care rationing (either directly or indirectly). The primary determinant, however, is the ability to pay for services. Without this ability, services are denied; therefore, those without insurance that is accepted by a provider or institution or who do not have the money to pay out of pocket are unable to obtain services.

DIF: Cognitive Level: Apply (Application) REF: p. 132

2. Which of the following must a nurse be knowledgeable about to make decisions regarding the most cost-effective way to allocate health care resources?

a.
Insurance resources
b.
Health care rationing
c.
Health economics
d.
Medical technology

ANS: C

Economics is the science concerned with the use of resources; health economics is concerned with how scarce resources affect the health care industry. The other options are important components of health economics but by themselves do not provide the broad understanding called for in this question.

DIF: Cognitive Level: Understand (Comprehension) REF: p. 130

3. Which of the following individuals would most likely experience a barrier when accessing health care?

a.
A 40-year-old female who speaks English
b.
A 25-year-old female with health insurance
c.
A 50-year-old male with hypertension
d.
A 30-year-old male who is unemployed

ANS: D

Barriers to accessing care include the inability to afford health care, lack of transportation, physical barriers, communication problems, child care needs, lack of time or information, or refusal of services by providers. The unemployed male is most likely to experience a barrier because of not having a job, which may reduce his access to health insurance and limit his income.

DIF: Cognitive Level: Analyze (Analysis) REF: p. 131

4. Which person is most likely to be uninsured?

a.
An 82-year-old woman with chronic medical problems
b.
A 2-year-old whose mother is on welfare
c.
A 50-year-old business man who works for a large corporation
d.
A 32-year-old man who works part-time at a small business

ANS: D

The typical uninsured person is one who works at a low-paying job, part-time or temporary, or at a small business. The elderly person would be eligible for Medicare, and the 2-year-old is probably eligible for Medicaid. The man who works at the large corporation probably has health insurance, because most large businesses provide it.

DIF: Cognitive Level: Analyze (Analysis) REF: pp. 131-132

5. Which of the following is most closely correlated with poor health?

a.
Age and gender (i.e., older males)
b.
Low socioeconomic status
c.
Minority race status
d.
High-risk lifestyle behaviors

ANS: B

Poverty is more closely related to health status even when controlling for age, gender, race, education, and lifestyle behaviors.

DIF: Cognitive Level: Understand (Comprehension) REF: p. 132

6. A pregnant teenager has approached a nurse asking about ways to improve the health outcomes for her and her unborn child. Which of the following statements would be most appropriate for the nurse to make?

a.
“Don’t drop out of school.”
b.
“Sign up for childbirth classes.”
c.
“Sign up for the WIC program.”
d.
“Take your prenatal vitamins daily.”

ANS: A

The question specifies the health of both the mother and the child. Socioeconomic conditions improve with education. Because socioeconomic status is inversely related to mortality and morbidity, by becoming better educated, the mother-to-be will be less likely to live a life of poverty and, as a consequence, will enjoy a greater chance of better health for herself and for her child.

DIF: Cognitive Level: Analyze (Analysis) REF: p. 132

7. A nurse is providing care to a child whose parents do not receive health insurance as an employee benefit and who do not have the financial resources to pay for health care out of pocket. Which of the following resources should the nurse recommend to the family?

a.
A managed care organization
b.
An emergency department
c.
Medicaid
d.
Medicare

ANS: C

Medicaid provides coverage for adults with low income and their children.

DIF: Cognitive Level: Apply (Application) REF: p. 132

8. Which of the following best explains how the government inadvertently encourages low-income persons to use emergency departments as their primary care provider?

a.
A huge amount of paperwork is required when Medicaid clients go to a physician’s office.
b.
Government regulations require Medicaid clients to use emergency departments when their primary health care provider is unavailable.
c.
Legally, emergency departments must see clients even if clients can’t pay.
d.
Physicians’ limited office hours make them unavailable during evenings and weekends.

ANS: C

People on Medicaid frequently have no primary care provider and may not be able to pay for their care. Although physicians can choose clients based on their ability to pay, emergency departments are required by law to evaluate every client regardless of ability to pay. Emergency department copayments are modest and are frequently waived if the client is unable to pay. Thus, low out-of-pocket costs provide incentives for Medicaid clients and the uninsured to use emergency departments for primary care services.

DIF: Cognitive Level: Understand (Comprehension) REF: p. 132

9. Of the four main factors that affect health, which is the least important?

a.
Environment
b.
Human biology
c.
Lifestyle choices
d.
Health care system

ANS: D

Of the four major factors that affect health—personal behavior (or lifestyle), environmental factors (including physical, social, and economic environments), human biology, and the health care system—medical services are said to have the least effect. Behavior (lifestyle) has been shown to have the greatest effect, but environment and biology account for 70% of all illnesses.

DIF: Cognitive Level: Understand (Comprehension) REF: p. 133

10. A nurse is trying to maximize the quality of life of her clients while reducing health care costs. Which of the following actions would most likely be completed by the nurse?

a.
Assisting in cast application for a client who was injured in a skateboard incident
b.
Irrigating the eyes of a client splashed with chemicals
c.
Restoring a normal cardiac rhythm following cardiopulmonary resuscitation of a client with a heart condition
d.
Teaching a high school boy about sexually transmitted infections and proper condom application

ANS: D

Education is primary health care prevention. A proactive investment in disease prevention and health promotion targeted at improving health behaviors and lifestyle has the potential to improve health status and reduce health care costs.

DIF: Cognitive Level: Analyze (Analysis) REF: p. 133

11. Which of the following caused health care providers to begin to focus on individual infections and trauma in the 1900s in the United States?

a.
Education of health care providers moved into universities.
b.
People finally had enough money to pay for medical care.
c.
The improved outcomes of hospital care were recognized.
d.
Advances were made in safe water, sewage disposal, and pasteurization of milk.

ANS: D

Environmental conditions influencing health began to improve with major advances in water purity, sanitary sewage disposal, milk quality, and urban housing quality. The health problems of this era were no longer mass epidemics but individual acute infections or traumatic episodes.

DIF: Cognitive Level: Understand (Comprehension) REF: p. 135

12. Which of the following accurately describes a challenge that will be faced by health care providers in the twenty-first century?

a.
Lack of available space to provide care for clients in hospitals
b.
Emergence of new and old communicable and infectious diseases
c.
New guidelines for chronic disease management
d.
Increased use of technology leading to a decreased need for health care workers

ANS: B

In the twenty-first century the emergence of new and the reemergence of old communicable and infectious diseases are occurring as well as larger foodborne disease outbreaks and acts of terrorism. Care for clients continues to move out of the hospital setting and into the community. Chronic disease management will be a challenge for health care providers; however, new guidelines should ease the care provided for these diseases and wouldn’t be seen as a challenge. The use of technology will continue to increase, but the need for health care workers will not be decreasing. New health care careers will emerge because of the changes in technology.

DIF: Cognitive Level: Understand (Comprehension) REF: p. 137

13. Which of the following demographic factors is expected to have the greatest influence on national health care spending?

a.
The aging population
b.
Use of diagnosis-related groups to determine reimbursement
c.
Insurance reform
d.
An increasing number of people without health insurance

ANS: A

The aging population is expected to affect health services more than any other demographic factor. The majority of older adults rely on publicly funded programs. As the baby boom generation ages and retires, federal expenses for Social Security and health care will increase.

DIF: Cognitive Level: Understand (Comprehension) REF: pp. 139-140

14. Which of the following groups pays the largest amount for health care in the United States today?

a.
Consumers
b.
Federal and state government
c.
Insurance companies and other third-party payers
d.
Hospitals and health care providers

ANS: B

Health care financing has evolved from a time when the most money was expended by consumers, then to a system financed by third-party payers such as insurance companies, and finally, to today, when state and federal government payments (primarily through Medicare and Medicaid) pay more than private insurance companies or consumers.

DIF: Cognitive Level: Remember (Knowledge) REF: p. 140

15. Which of the following services would be covered under Medicare Part A?

a.
Blood draw to assess PT/INR
b.
Physical therapy visit
c.
Stay in skilled nursing facility
d.
Transportation by an ambulance

ANS: C

Medicare Part A covers hospital care, home care, and skilled nursing care.

DIF: Cognitive Level: Analyze (Analysis) REF: pp. 141-142

16. A Medicare recipient has elected to pay a monthly premium for Medicare that will cover expenses such as laboratory services and equipment. Which of the following best describes this part of Medicare?

a.
Part A
b.
Part B
c.
Part C
d.
Part D

ANS: B

Medicare Part B is a supplemental (voluntary) program; it provides coverage for services that are not covered by Part A, such as laboratory services, ambulance transportation, prostheses, equipment, and some supplies.

DIF: Cognitive Level: Apply (Application) REF: p. 142

17. Which of the following criterion is now used for deciding the amount of the reimbursement before care is provided?

a.
A proportion of actual cost arbitrarily decided by the Medicare panel
b.
The federal budget constraints for the current fiscal year
c.
Hospital and health care provider feedback and political persuasion
d.
Prospective payment scale based on the medical diagnosis

ANS: D

As a result of rising health costs, Congress passed a law in 1983 that mandated an end to cost-plus reimbursement and instituted a prospective payment system (PPS) for inpatient hospital services to shift the cost incentives away from the providing of more care and toward more efficient services. The basis for prospective reimbursement is the 468 diagnosis-related groups (DRGs).

DIF: Cognitive Level: Remember (Knowledge) REF: p. 142

18. Which of the following payment systems tries to keep clients healthy through education and health promotion, with the goal of reducing the need for professional health care intervention and therefore also lowering cost?

a.
Managed care plan
b.
Fee-for-service payment
c.
Prospective reimbursement
d.
Retrospective reimbursement

ANS: A

Fee-for-service payment encourages more services to be given. Reimbursement, whether prospective or retrospective, is based on the same criteria, but managed care integrates the financing and the delivery of health care. The concept of managed care is that costly care could be reduced if consumers had access to education and health promotion.

DIF: Cognitive Level: Remember (Knowledge) REF: p. 145

19. Which of the following terms describes when a nurse practitioner receives a set monthly payment to take care of a group of clients regardless of the services needed and provided?

a.
Capitation
b.
Fee for service
c.
Rationing
d.
Retrospective reimbursement

ANS: A

In payment by capitation, practitioners are paid a set amount to provide care to a given client or group of clients for a set period of time.

DIF: Cognitive Level: Remember (Knowledge) REF: p. 146

20. A client expresses concern that health care coverage based on capitation may have negative side effects. Which of the following would most likely be a consequence of capitation?

a.
Coercing clients to attend health promotion education classes
b.
Encouraging clients to seek care elsewhere
c.
Increasing the number of interventions to maximize payment
d.
Neglecting to order certain tests or treatment to minimize cost to the provider

ANS: D

In capitated arrangements, physicians and other practitioners are paid a set amount to provide care to a given client for a set period of time and amount of money. Thus, neglecting to order certain tests or treatment would be a way for the provider to maximize the amount of money received to provide care to members of this group.

DIF: Cognitive Level: Analyze (Analysis) REF: p. 146

21. A public health nurse is counseling a client who is trying to determine if a health maintenance organization (HMO) or preferred provider organization (PPO) will provide the better health care coverage. Which of the following best describes one main difference between these two types of coverage?

a.
HMOs provide comprehensive care to members for a fixed fee.
b.
PPOs designate providers that members can choose.
c.
PPOs provide one model of care delivery.
d.
HMOs provide financial incentives to encourage members to select HMO providers.

ANS: A

The HMO is a provider arrangement whereby comprehensive care is provided to members for a fixed, “per member per month,” fee. A PPO uses predetermined rates for services to be delivered to members. HMOs do not have one model of care delivery. PPOs provide financial incentives to encourage members to select PPO providers.

DIF: Cognitive Level: Analyze (Analysis) REF: p. 145

22. A nurse is implementing a primary prevention strategy focusing on economics within the community. Which of the following interventions is the nurse most likely completing?

a.
Applying for a grant to establish a day care center to serve dependent older adult clients living with working families
b.
Persuading legislators to pass a bill offering health care financial aid to families at risk
c.
Screening cocaine addicts for financial assistance eligibility for drug treatment
d.
Referring clients with renal failure to apply for Medicare

ANS: B

Primary prevention occurs before an illness or condition develops. Of the options provided, only persuading legislators to pass a bill offering health care financial aid to families at risk addresses initiating interventions beforean illness occurs.

DIF: Cognitive Level: Apply (Application) REF: p. 133

MULTIPLE RESPONSE

1. In which of the following situations would the federal government provide money through tax relief for private enterprise? (Select all that apply.)

a.
A business pays for part of health insurance premiums for its employees
b.
A business purchases gifts for its employees to award them for their service
c.
An employer provides health screenings and immunizations
d.
An employer requests reimbursement for employee transportation costs

ANS: A, C

Businesses can pay for disease prevention and health promotion services for employees (and sometimes their families) in the form of immunizations, health screenings, and counseling. The business can then deduct these costs as a business expense, which reduces the amount the business owes the government in taxes on their profits. Similarly, when businesses subsidize health insurance for their employees—and families—this is also a business expense, which decreases the amount the business would otherwise pay in taxes. Thus, the government indirectly provides the money, but the business, a part of the private sector, decides how it is used.

DIF: Cognitive Level: Apply (Application) REF: p. 131

2. Which of the following best explains why clients who have Medicaid have poor health outcomes? (Select all that apply.)

a.
Clients may have preexisting conditions not covered by insurance.
b.
Many physicians won’t accept Medicaid clients.
c.
Medicaid won’t pay for certain medical interventions.
d.
Medicaid recipients are noncompliant with their health care providers’ recommendations.

ANS: A, B, C

The primary reasons for delay, difficulty, or failure to access care include inability to afford health care and a variety of insurance-related reasons, including the insurer not approving, covering, or paying for care; the client having preexisting conditions; and physicians refusing to accept the insurance plan. Practical problems such as lack of childcare, transportation, long waiting periods, and communication issues also interfere.

DIF: Cognitive Level: Understand (Comprehension) REF: p. 132

3. A nurse would like to help members of the community focus on receiving primary preventive health care services. Which of the following interventions should be implemented by the nurse? (Select all that apply.)

a.
Publicize data on success of health promotion efforts, including cost savings.
b.
Lobby for decreased reimbursement for secondary and tertiary care services.
c.
Establish standards for appropriate screenings at specific intervals.
d.
Encourage members of the military service to engage in appropriate healthy lifestyle behaviors.

ANS: A, C

Reasons given for the lack of emphasis on prevention in clinical practice and lack of financial investment in prevention include provider uncertainty about which clients should receive services and at what intervals, lack of information about preventive services, negative attitudes about the importance of preventive care, lack of time for delivery of preventive services, delayed or absent feedback regarding success of preventive measures, less reimbursement for these services than for curative services, lack of organization to deliver preventive services, and lack of use of services by the poor and elderly. Although all of the above suggestions may have some merit, some would be illegal, such as requiring people to change their lifestyle.

DIF: Cognitive Level: Analyze (Analysis) REF: p. 133

4. Which of the following are some major differences in health care today, as compared with the first half of the twentieth century? (Select all that apply.)

a.
Consumers are influenced by advertising for specific health care agents or procedures.
b.
The emphasis is on the continued expansion of health care facilities, especially acute care hospitals.
c.
Education and specialization of personnel have increased.
d.
The need to create new ways to pay for health care is a central focus.

ANS: A, C

Since the 1980s, the United States has been in a period of limited resources, with an emphasis on containing costs, restricting growth in the health care industry, and reorganizing care delivery. Results have included shorter hospital stays and substitution of one set of personnel (such as nurse practitioners) for another set (physicians). Such trends are made more challenging by increased direct marketing to consumers. Also with increased knowledge has come increased education and specialization.

DIF: Cognitive Level: Understand (Comprehension) REF: pp. 136-137