NUR 4837 Complete Solution Guide(2023-2024) 100% verified
Care Coordination and "Gatekeeper" - (correct 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. - (correct answer)- Biomedical model
- Financial incentive for physician specialization and hospital expansion
- Professionalism
Medicare - (correct answer)Medicare is for the elderly
Part A of Medicare - (correct answer)Hospital insurance plan for the elderly financed largely through
social security taxes from employers and employees
Part B of Medicare - (correct answer)Insures the elderly for physician services and is paid for by
federal taxes and monthly premiums from the beneficiaries
Part D of Medicare - (correct answer)Offers prescription drug coverage and is paid for by federal
taxes and monthly premiums from beneficiaries.
Medicaid - (correct answer)A 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 - (correct answer)This 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) - (correct 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) - (correct 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.
, NUR 4837 Complete Solution Guide(2023-2024) 100% verified
First Generation Health Maintenance Organizations and Vertical Integration: The Kaiser- Permanente
Medical Care Program - (correct 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" - (correct answer)-
Network Model HMOs
- Independent Practice Associations
- Integrated Medical groups
Independent Practice Association (IPAs) - (correct 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 - (correct answer)**Second Generation HMO**
- Physicians can establish contractual relationships with numerous HMOs and IPAs. They represent
an alternative to the vertically integrated HMO. Managed care relationships involving IPAs and
medical groups consist of a network of contractual links between HMOs and autonomous physician
groups, hospitals, and other provider units, rather than the "everything-under-one-roof" model of
vertical integration. Observers have dubbed the network forms of managed care organization
"virtual integration," signifying an integration of services based on contractual relationships rather
than unitary ownership. In these virtually integrated systems, HMOs do not directly provide health
services through their own hospitals and physician organizations.
Integrated Medical Groups - (correct answer)**Second generation HMO**
- These groups have tighter organizational structures than IPAs, consisting of groups in which
physicians no longer own their own practices and office assets, but become employees of an
organization that owns and manages their practice. Similar to IPAs, they contract with multiple
Care Coordination and "Gatekeeper" - (correct 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. - (correct answer)- Biomedical model
- Financial incentive for physician specialization and hospital expansion
- Professionalism
Medicare - (correct answer)Medicare is for the elderly
Part A of Medicare - (correct answer)Hospital insurance plan for the elderly financed largely through
social security taxes from employers and employees
Part B of Medicare - (correct answer)Insures the elderly for physician services and is paid for by
federal taxes and monthly premiums from the beneficiaries
Part D of Medicare - (correct answer)Offers prescription drug coverage and is paid for by federal
taxes and monthly premiums from beneficiaries.
Medicaid - (correct answer)A 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 - (correct answer)This 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) - (correct 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) - (correct 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.
, NUR 4837 Complete Solution Guide(2023-2024) 100% verified
First Generation Health Maintenance Organizations and Vertical Integration: The Kaiser- Permanente
Medical Care Program - (correct 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" - (correct answer)-
Network Model HMOs
- Independent Practice Associations
- Integrated Medical groups
Independent Practice Association (IPAs) - (correct 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 - (correct answer)**Second Generation HMO**
- Physicians can establish contractual relationships with numerous HMOs and IPAs. They represent
an alternative to the vertically integrated HMO. Managed care relationships involving IPAs and
medical groups consist of a network of contractual links between HMOs and autonomous physician
groups, hospitals, and other provider units, rather than the "everything-under-one-roof" model of
vertical integration. Observers have dubbed the network forms of managed care organization
"virtual integration," signifying an integration of services based on contractual relationships rather
than unitary ownership. In these virtually integrated systems, HMOs do not directly provide health
services through their own hospitals and physician organizations.
Integrated Medical Groups - (correct answer)**Second generation HMO**
- These groups have tighter organizational structures than IPAs, consisting of groups in which
physicians no longer own their own practices and office assets, but become employees of an
organization that owns and manages their practice. Similar to IPAs, they contract with multiple
