[community Public Health] Chapter 3: The United State Health care System

Managing third-party reimbursement is considered to be a responsibility of an insurance company. This involves handling the process of reimbursing healthcare providers for services rendered to policyholders. Insurance companies negotiate contracts with healthcare providers, determine the reimbursement rates, and process and approve claims for payment. They are responsible for ensuring that the claims are accurate, appropriate, and compliant with the terms of the insurance policy. By managing third-party reimbursement, insurance companies play a crucial role in facilitating the financial transactions between healthcare providers and policyholders.

The nurse would best describe the American health care system as being in the midst of ongoing change that offers real opportunities. This suggests that the system is dynamic and evolving, presenting possibilities for improvement and advancement.

Managed care is a model that aims to ensure maximum value received from the resources used in healthcare. This means that the goal of managed care is to optimize the use of resources, such as medical treatments and services, to provide the best possible outcomes for patients while minimizing unnecessary costs. By implementing managed care, healthcare providers can prioritize cost-effective and evidence-based practices, ultimately improving the overall quality and efficiency of healthcare delivery.

Decreasing poverty levels is considered the best method to improve poor health according to economists, sociologists, and political activists. Poverty is often associated with limited access to healthcare, unhealthy living conditions, and inadequate nutrition, all of which contribute to poor health outcomes. By addressing poverty and improving socioeconomic conditions, it is believed that overall health in the community can be improved. Increasing funding to health care, increasing the number of outpatient clinics, or decreasing the number of specialty physicians may have some impact on health, but addressing poverty is seen as a more effective and comprehensive approach.

The most appropriate data for the nurse to use in examining the effectiveness of a health care system would be the health of the population served. This data would provide insight into the overall impact and outcomes of the system on the health of the individuals it serves. By assessing the health of the population, the nurse can determine if the system is effectively meeting the needs of the community and achieving positive health outcomes.

Before 1965, most consumers and healthcare providers were not concerned about healthcare costs because expenses were paid by insurance reimbursement for employees who received insurance as a fringe benefit. This means that individuals did not have to directly bear the cost of healthcare services as it was covered by their insurance plans. Therefore, there was less incentive for consumers and healthcare providers to be concerned about the costs involved.

If a hospital is treating a urinary tract infection that occurred during hospitalization, it may no longer receive Medicare reimbursement. This is because Medicare reimbursement is typically provided for the treatment of conditions that were present upon admission to the hospital, rather than conditions that develop during the hospital stay. Therefore, treating a urinary tract infection that occurred during hospitalization would not be eligible for Medicare reimbursement.

The community/public health nurse would need to consult this client's physician because the physician is the primary care gatekeeper who determines appropriate referrals. This means that the physician has the authority to decide whether the client needs to be referred to other healthcare professionals or specialists for further evaluation or treatment. The nurse may need to consult the physician to discuss the client's health condition and determine if any referrals are necessary for the client's comprehensive care.

The main difference in the health care system in the United States between President Clinton's vision in 1994 and today's reality is the responsibility of oversight. In President Clinton's vision, oversight was primarily a public responsibility, meaning that the government had a significant role in regulating and monitoring the health care system. However, in today's reality, oversight is also shared with the private sector, with private organizations and insurance companies having a greater influence and responsibility in overseeing the health care system.

The correct answer is "The lowest life expectancy and highest infant mortality." This answer suggests that the U.S. health care system performs poorly in terms of life expectancy and infant mortality compared to other similar industrialized countries. This could be due to various factors such as disparities in access to healthcare, high healthcare costs, and inadequate preventive care measures.

Nurses differ from most other professional health care providers because they are primarily employees of an organization. This means that they work within a specific healthcare facility, such as a hospital or clinic, and are employed by that organization. Other healthcare providers, such as doctors or therapists, may have their own private practices or work independently. Being employees of an organization can impact the way nurses provide care and the structure of their work environment.

The Omnibus Budget Reconciliation Act of 1981 had the consequence of causing a rise in the number of uninsured Americans. This act made significant cuts to federal funding for Medicaid, which resulted in reduced access to healthcare for low-income individuals and families. As a result, many Americans who were previously covered by Medicaid became uninsured, leading to an increase in the overall number of uninsured individuals in the country.

The U.S. Department of Health and Human Services is the correct answer because it is the federal agency that is most involved in both direct and indirect health-related responsibilities. This department is responsible for protecting the health of all Americans and providing essential human services. It oversees various agencies and programs, including the Centers for Disease Control and Prevention, the Food and Drug Administration, and the National Institutes of Health. Through its direct involvement in healthcare delivery and its indirect responsibilities in policymaking and regulation, the Department plays a crucial role in promoting and maintaining public health in the United States.

The correct answer is The Constitution, which reserved for states all powers not specifically given to the federal government. The Constitution grants certain powers to the federal government, but any powers not explicitly given to the federal government are reserved for the states. This principle is known as federalism, and it allows states to have authority in various areas, including health care.

Understanding health behaviors is important for students in order to provide effective community/public health nursing care. By discussing the significant changes in the U.S. health care system, students can gain insight into how these changes impact health behaviors and the overall health of individuals and communities. This knowledge can help students develop strategies to promote healthy behaviors and prevent illness and disease. Additionally, understanding health behaviors is essential for students to effectively communicate and educate individuals and communities about health promotion and disease prevention.

The correct answer is "It is decentralized and expensive." This means that the U.S. health care system is not centrally controlled and instead operates through a variety of private and public entities. It also implies that health care in the U.S. is costly, often leading to financial burdens for individuals and families.

The correct answer is private system for those who can pay and public system for some of the poor. This answer accurately describes the two systems of healthcare that exist in the United States. The private system refers to healthcare services that are provided by private insurance companies and healthcare providers, which individuals can access if they can afford to pay for it. The public system, on the other hand, refers to government-funded healthcare programs such as Medicaid and Medicare, which provide healthcare coverage for low-income individuals and certain vulnerable populations.

The nurse would respond that the political influence held by those with a strong interest in maintaining the current system has prevented the change to a single-payer system. This implies that there are powerful individuals or groups who benefit from the current system and have the ability to prevent any major changes from occurring.

The federal government obtains its authority to be involved in health care from the regulation of interstate commerce and its responsibility to provide for the general welfare. This means that the federal government can regulate health care activities that cross state lines and can also provide for the well-being and welfare of its citizens by ensuring access to healthcare services. This authority is derived from the Constitution, which allocates authority for health care to the federal government.

The unique feature of the American Heart Association is using creative approaches to solve health problems. This sets them apart from other organizations as they focus on finding innovative solutions to address health issues. They may utilize unconventional methods, technologies, or strategies to tackle these problems in a more effective and efficient manner. This approach allows them to constantly adapt and improve their efforts in promoting heart health and preventing cardiovascular diseases.

In the 1960s, public health lost power and influence primarily because it had already made significant progress in reducing many life-threatening health problems. As a result, the urgency and perceived importance of public health initiatives decreased, leading to a decline in its power and influence.

After the introduction of Medicare and Medicaid in the 1960s, the most costly category of health care was hospital care. This can be attributed to the fact that these government programs provided coverage for hospital stays and medical procedures, leading to an increase in the utilization of hospital services. As a result, the demand for hospital care rose significantly, leading to higher costs in this category of health care.

This client most likely has a preferred provider organization (PPO) health insurance plan. PPO plans typically have a looser organizational structure and do not require primary care physician approval before seeing a specialist. In a PPO plan, clients have the flexibility to see any healthcare provider they choose, although they may receive greater benefits if they use providers within the plan's network.

The nurse would have included information about action plans being focused on changing lifestyles to reduce risks and prevent problems in the presentation. This is because action plans are an important component of achieving national health goals, and they typically involve interventions and strategies aimed at promoting healthy behaviors and reducing the prevalence of risk factors for various health problems. By emphasizing the importance of lifestyle changes, the nurse would have highlighted the role of individual behavior in improving health outcomes and preventing diseases.

The most likely root cause of the conflict between an insurance company and a physician is the distribution of power. This suggests that there is a disagreement or imbalance in the authority and control within the relationship between the two parties. It could be that the insurance company is exerting too much control over the physician's decisions or that there is a dispute over the allocation of power and decision-making responsibilities. This conflict may arise from differing perspectives on how power should be distributed and exercised in the context of their professional relationship.

This option is the most likely to be included because it provides information about the organizational structure of state health agencies, indicating that they have multiple departments, commissions, agencies, and boards. This suggests that state health agencies are complex and have various components that work together to provide services to citizens.

The accurate statement for the nurse to make is "Little progress; no state has completely done so." This means that there has been minimal progress in consolidating state health services into a single agency, and no state has fully achieved this goal.

The responsibilities of the local health department would include addressing needs that have been delegated by state health agencies. This means that the local health department would be responsible for carrying out specific tasks and initiatives that have been assigned to them by the state health agencies. This could include implementing programs, providing services, and meeting the needs of vulnerable populations based on the directives and priorities set by the state health agencies.

HMOs operate by organizing a network of healthcare providers who offer services for a predetermined fee. This means that the client will have access to a specific group of healthcare providers who have agreed to provide services within the HMO network. The client will typically pay a fixed fee, such as a monthly premium, in exchange for this access. This arrangement helps to control costs and ensure that the client receives care within the designated network of providers.

The purpose of referring a client to the managed care service provided by the hospital is to review the care being provided and eliminate any unnecessary services. This ensures that the client is receiving the most appropriate and cost-effective care, while also avoiding any unnecessary medical interventions or treatments. By reviewing the care plan, the managed care service can identify any services that may not be beneficial or essential to the client's needs, thereby optimizing the care provided.

The client would go to a local hospital to receive care. Local hospitals typically provide care to all individuals regardless of their veteran status or ability to pay. These hospitals are funded by the local community and often have programs in place to assist individuals who cannot afford healthcare.