NUR 4837 Healthcare Policy and Finance Final 2026/2027 (15pages)

Care Coordination and "Gatekeeper" - answer- The primary care provider is the gatekeeper Example: Polly sees a nurse practitioner who discovers that the reason she is vomiting is due to the medication she is taking. The NP consults with the oncologist to change her medication/prescription Forces driving healthcare in the U.S. - answer- Biomedical model - Financial incentive for physician specialization and hospital expansion - Professionalism Medicare - answerMedicare is for the elderly Part A of Medicare - answerHospital insurance plan for the elderly financed largely through social security taxes from employers and employees Part B of Medicare - answerInsures the elderly for physician services and is paid for by federal taxes and monthly premiums from the beneficiaries Part D of Medicare - answerOffers prescription drug coverage and is paid for by federal taxes and monthly premiums from beneficiaries. Medicaid - answerA program run by the states and is funded by federal and state taxes, which pays for the care of millions of LOW-INCOME PEOPLE Fee- for- Service Payment with Utilization Review - answerThis is the traditional type of payment, with the addition that the third-party payer, whether private insurance company or government agency, assumes the power to authorize or deny payment for expensive medical interventions such as hospital admissions, extra hospital days, and surgeries. Preferred Provider Organization (PPO) - answer-These are organizations in which insurers' contract with a limited number of physicians and hospitals who agree to care for patients, usually on a discounted fee-for-service basis with utilization review (the insurer authorizes/denies payment for services deemed unnecessary). -Patients are able to see physicians not included within their insurer's physician network if they desire, but have to pay a higher share of "out of pocket" costs as a result when they use physicians/hospitals outside the "preferred" network. -PPO's allow patients to choose their own providers outside of a traditional HMO model. However, there may be increased costs to the patient in this type of model compared with HMO models Health Maintenance Organization (HMO) - answer-These organizations require patients to receive their care from physicians and hospitals within their designated HMO. -They are prepaid medical group services available through large businesses, instead of the traditional fee-for-service model. First Generation Health Maintenance Organizations and Vertical Integration: The KaiserPermanente Medical Care Program - answer- Vertical integration refers to consolidating under one organizational roof and common ownership all levels of care, from primary to tertiary care and the facilities and staff necessary to provide this full spectrum of care Example: Mario Fuentes was a professor at UCLA. The university paid for his family's premium for the Kaiser Health plan. He fractured his clavicle and went to a Kaiser urgent care clinic. His wife suffered from RA and went to their physician at the Permanente medical clinic. Their kid got into a car accident and went to a random hospital not under their insurance plan but he was immediately transported to Kaiser's regional neurosurgery center in California to go into surgery Second- Generation Health Maintenance Organizations and "Virtual Integration" - answerNetwork Model HMOs - Independent Practice Associations - Integrated Medical groups Independent Practice Association (IPAs) - answer**Second Generation HMO** - Organizations that help solo practitioners contract with other HMOs. The IPAs negotiate and administer HMO contracts for their physicians Example: As more and more of her patients switched from fee-for-service plans to the new HMO plans run by commercial insurers, Dr. Westcoast figured she had no choice but to start contracting with these HMOs if she wanted to retain her patients. She joined an IPA that helped solo practitioners like her to contract with different HMOS. Within 3 years, 30% of her patients were covered by 4 HMO plans that contracted with Good Health IPA Network HMOs - answer**Second Generation HMO**