Download - Reimbursement, Medicare, And Medicaid
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Fall 2013
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Gross domestic product (GDP) is the broadest
measure of the health of the US economy.
Real GDP: output of goods and services
produced by labor and property located inthe United States
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Unnecessary care
Consumer attitudes
Healthcare financing
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Pharmaceutical usage
Changing population demographics
Disease patterns
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Health disparities based on gender, race, and
socioeconomic status continue.
US infant mortality is among the highest in
the world.US life expectancy is lower than in many
other developed countries.
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Four sources
Government (45%)
Private insurance companies (35.9%)
Individuals (15%) Other (4%)
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Enacted 1965
Federal funding and control
Not means-tested (income not considered)
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Fees paid strictly controlled in 1965 plan
But new technology not foreseen
People are living longer
Burgeoning costs led to a series of costcontrol efforts
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Enacted 1982
Prospective payment system
Payment per case
Diagnosis-related groups
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Potential for legal gaming of the system
DRG creep to higher-level diagnoses
Some suggest DRGs should have been based
on severity, not diagnosis
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State level program
Medically indigent, blind, or disabled
Children with disabilities 50% to 83% paid by federal government
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Enacted 1965
Federal and state funding
Administered by the states
Covers the poorMeans tested
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Largest groups covered are women and
children
But largest expenditures are for aged and
disabled
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Also the target of cost control efforts
Waivers and demonstration projects provided
for state experimentation
Goal was to cover more of a statespopulation
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Managed care is a health plan that brings together
the delivery and financing function into one
entity. The goal is to decrease unnecessary
services, thereby decreasing costs.
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Military health plan
Serves:
Active duty personnel and family
Survivors of military personnel
Retired military personnel
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Provides healthcare services
to former military personnel
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Private Insurance
Individual insurance plan, the insured pays the total
amount of the monthly premium
Group insurance plan
the insured individual and their employer share the
amount of the monthly premium
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Health Maintenance Organizations care is directed toward prevention of disease
patient must see only HMO approved providers
pay a monthly fee, no additional charge for care
care from non-HMO provider generally not covered
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Preferred Provider Organization (PPO) Group of doctors and/or hospitals that provide care to a
specific group
PPO provides services to the insured at a reduced rate Usually require a deductible and a co-pay
Less coverage for treatment provided by non-PPOprovider
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Indemnity PlanTraditional plan with freedom to visit
physician of choice
No referral required by insurance company
Pay up front
Get reimbursed amount allowed by insurance
policy; amounts may vary
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We must think of our practice within a
context of organizational viability and quality
of care.
We must be able to do financial thinking.We must think of our services in terms of
value added for patients.
We must exercise cost-conscious nursing
practices, including capturing all costs.
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We must focus on patient needs, not provider
needs or organizational practices.
We must provide evidence-based practices
for the public we serve.We must incorporate and evaluate new
technologies.
We must use research to better our
practices.
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Accreditation and reimbursement agencies
require accurate and thorough documentation of
the nursing care rendered and the clientsresponse to interventions.
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Strand, J., & Castillo, P. Reimbursement 101.
Retrieved August 23, 2013, from
http://www.paeaonline.org/Project04/PM/html/reimbursement/remPPT.htm.
Yoder-Wise, P. S. (2010). Leadership and
Managing in Nursing, 5thEdition, Mosby
Elsevier.
http://www.paeaonline.org/Project04/PM/html/reimbursement/remPPT.htmhttp://www.paeaonline.org/Project04/PM/html/reimbursement/remPPT.htmhttp://www.paeaonline.org/Project04/PM/html/reimbursement/remPPT.htmhttp://www.paeaonline.org/Project04/PM/html/reimbursement/remPPT.htm