Health care finance, economics, and policy for nurses : a foundational guide

329 Pages·2022·2.737 MB·English

by  Betty Rambur

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HEALTH CARE FINANCE, ECONOMICS, AND B
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POLICY FOR NURSES BETTY RAMBUR
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A F O U N D AT I O N A L G U I D E A
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Second Edition
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Betty Rambur, PhD, RN, FAAN C HEALTH CARE FINANCE,
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“[This book] will change how you practice, how you think about health care, and your
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contributions as a nurse, and it will better prepare you to thrive and advance in the future.”
IN ECONOMICS, AND
—Peter I. Buerhaus, PhD, RN, FAAN, FAANP(h) A
Professor of Nursing
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Director, Center for Interdisciplinary Health Workforce Studies
Montana State University C
From the Foreword E
POLICY FOR NURSES
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This succinct, engaging text for graduate and undergraduate nursing programs distills the complexities E
of health care finance, economics, and policy into a highly accessible resource that can be applied to any C
practice setting. It presents economic and financial dynamics in health care as a precursor to policy and O
advocacy in nurses. The second edition adds graduate-level considerations and is updated to reflect our N
current political and legislative landscape.
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Real-life illustrations support foundational concepts and interactive quizzes reinforce information.
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Faculty resources include PowerPoint slides, a test bank, and an instructor’s manual including a sample
syllabus. I
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New to the Second Edition: S A F O U N D A T I O N A L G U I D E
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New chapter on early lessons from COVID-19
• Adds graduate-level considerations to content N
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Updated to reflect current political and legislative landscape D
• A F o u n d a t i o n a l G u i d e
Expands payment section to include advanced practice roles Second Edition
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Includes updated information on the Patient Protection and Affordable Care Act, The Tax Cuts
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and Jobs Act, and Supreme Court deliberations
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Key Features: IC
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• Presents complex concepts in easy-to-understand language F
Addresses policy and payment competencies that align with nursing program accreditation criteria
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Breaks down complex financial principles to educate nurses with no prior understanding of
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health care finance
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Includes practical, accessible real-life examples to help make sense of complex health care systems N
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• Provides interactive quizzes so readers can test knowledge U
Includes a step-by-step, skill-building guide to enhance professional influence through R
• participation on governing boards S
Compatible with online teaching and coursework
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Purchase includes digital access for use on most mobile S
devices or computers ISBN 978-0-8261-5253-4
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New York, NY 10036-8002
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Health Care Finance, Economics,
and Policy for Nurses
Betty Rambur, PhD, RN, FAAN, is the Routhier Endowed Chair for Practice and
professor of nursing at the University of Rhode Island. She was formerly professor of
nursing and health policy at the University of Vermont and from 2000 to 2009 served
as an academic dean. In this role, she led the merger of the School of Nursing and the
School of Health Sciences to establish the College of Nursing and Health Sciences.
These experiences have built on Dr. Rambur’s substantive leadership history
in health policy and finance. From 1991 to 1995, she led the statewide health financ-
ing reform effort in North Dakota. In August 2013, Dr. Rambur was appointed to
Vermont’s Green Mountain Care Board by Vermont’s Governor Peter Shumlin, and
she served in that role until 2017. The five-member Green Mountain Care Board
is a quasijudicial body. It oversees Vermont’s financing, payment, and delivery
reform and holds board regulatory, innovation, and evaluation authority. In May
2020, Dr. Rambur was appointed to the Medicare Payment Advisory Commission
(MedPAC)* by the U.S. Comptroller General, Eugene Louis Dodaro, Director of the
U.S. Government Accountability Office. MedPAC, an influential, nonpartisan group,
advises the U.S. Congress on Medicare issues.
An RN, Dr. Rambur received her MS and PhD in nursing from Rush University
in Chicago, Illinois, Family Nurse Practitioner Certificate from the University of North
Dakota, and baccalaureate degree from the University of Mary, Bismarck, North
Dakota, where she also served as the Department Chair. She maintains an active
research program focused on health services, quality, workforce, waste and cost reduc-
tion, and ethics. She has led or participated in research, education, and public ser-
vice grants exceeding $2 million; is the author of about 60 published articles; and has
made numerous invited presentations on her research, health care economics and pol-
icy, and leadership development. In 2007, her research was honored by Sigma Theta
Tau International. Dr. Rambur is also an accomplished teacher in both classroom and
online venues. In May 2013, she received the University of Vermont Graduate Student
Senate Excellence in Teaching Award, and in November 2013, she received the pres-
tigious Sloan Consortium's Excellence in Online Teaching and Learning Award. Her
teaching expertise includes the organization, finance, and policy of health care, pay-
ment reform, and evidence-based practice.
*The orientation detailed in this text is that of the author and does not represent MedPAC policy.
Health Care Finance, Economics,
and Policy for Nurses
A Foundational Guide
Second Edition
Betty Rambur, PhD, RN, FAAN
Copyright © 2022 Springer Publishing Company, LLC
All rights reserved.
First Springer Publishing edition 2015.
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Springer Publishing Company, LLC
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Acquisitions Editor: Joseph Morita
Compositor: Transforma
ISBN: 978-0-8261-5253-4
ebook ISBN: 978-0-8261-5254-1
DOI: 10.1891/9780826152541
Qualified instructors may request supplements by emailing [email protected]
Instructor’s Syllabus ISBN: 978-0-8261-5255-8
Instructor’s PowerPoints ISBN: 978-0-8261-5257-2
Instructor’s Test Bank ISBN: 978-0-8261-5256-5
21 21 22 23 24 / 5 4 3 2 1
The author and the publisher of this Work have made every effort to use sources believed to be
reliable to provide information that is accurate and compatible with the standards generally
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Library of Congress Cataloging-in-Publication Data
Names: Rambur, Betty, author.
Title: Health care finance, economics, and policy for nurses : a foundational guide / Betty Rambur.
Description: Second edition. | New York, NY : Springer Publishing Company, LLC, [2022]
Identifiers: LCCN 2021004651 | ISBN 9780826152534 (paperback) | ISBN 9780826152541 (ebook)
Subjects: MESH: Healthcare Financing | Decision Making | Health Care Costs | Health Policy |
United States | Nurses Instruction
Classification: LCC RT86.7 | NLM W 74 AA1 | DDC 362.17/30681--dc23
LC record available at https://lccn.loc.gov/2021004651
Publisher’s Note: New and used products purchased from third-party sellers are not guar-
anteed for quality, authenticity, or access to any included digital components.
Printed in the United States of America.
Contents
Foreword to the Second Edition, Peter I. Buerhaus,
PhD, RN, FAAN, FAANP(h) ix
Foreword to the First Edition, Susan B. Hassmiller, PhD, RN, FAAN,
and Susan Reinhard, PhD, RN, FAAN xiii
A Note From the Author xv
How To Use This Text: A Note to Faculty xvii
Acknowledgments xxiii
SECTION I. T HE CONTEXT OF HEALTH CARE AND
HEALTH CARE REFORM 1
1. What Is Health Economics and Why Is It Important to Nurses? 3
Theoretical Economic Approaches 5
Social Determinants of Health 6
How Economics Differs From Financing and Reimbursement 8
2. A Story of Unintended Consequences: How Economic and
Policy Solutions Create New Challenges 25
The Influence of the Flexner Report 27
Early Hospitals 29
Social Reform Addressing Unintended Consequences of
Employer-Based Insurance 30
Attempts to Change Financial Incentives to Contain Costs 33
The Affordable Care Act and New (and Renewed) Payment Models 37
COVID-19 38
3. The Patient Protection and Affordable Care Act of 2010 45
The Patient Protection and Affordable Care Act of 2010 45
Insurance Access—Employer Mandates and Medicaid Expansion 47
Insurance Access—Expanded Eligibility 48
What About Those Who Are Still Not Covered By One of These
Mechanisms? 49
What Does the Health Care Exchange Do? 50
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vi Contents
Where Can a Nurse Direct a Patient Who Asks Questions About How to
Navigate the Complex Terrain of Health Insurance? 66
Insurance Lessons From COVID-19 66
4. Payment Reform 73
From Volume to Value: Payment Models That Move
Away From Fee-For-Service Reimbursement 74
Nursing Roles Within Emerging Payment Models 90
SECTION II. HEALTH CARE ECONOMICS: AN OVERVIEW 97
5. How Health Care Markets Differ From Classic Markets 99
What Does It Mean to Bear the Consequences of Financial
Decision-Making? 99
What Ideas Help Us Understand Overtreatment?
The Example of Small-Area Variation and
Supplier-Induced Demand 108
6. The Role of Information in Health Care Markets
and Decision-Making 117
The Need for Information 117
Data on Quality 125
Data Science 127
Information Science, Quality Science, and Data 134
7. Market Entry, Exit, and Antitrust Law 143
Entering and Exiting the Market 144
Merge, Consolidate, or Stand Alone: An Overview
of Antitrust Law 149
Is Consolidation the Same as Integration? 149
SECTION III. E THICS AND ECONOMICS IN AN AGE OF REFORM 155
8. What Is Ethinomics? 157
Can Economics Coexist With the Intention of “Doing Good”? 157
Social Determinants of Health, Health Disparities, Ethics, and
Economics 160
Moral Conduct of Nurses in Contemporary Complexity 165
9. Additional Models to Guide Ethical Decision-Making 173
Consequence-Based Decision-Making 174
Deontology: Rule-Based Decision-Making 175
Virtue Ethics 176
Using These Models in Clinical Decision-Making 177
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Contents vii
Moral Distress 179
Ethics and Clinical Decision-Making During Pandemics 180
Ethics of Reform and Cost Containment 182
Sustainability Is an Ethical Issue 184
Nurses on Boards and in Politics 185
SECTION IV. PULLING IT ALL TOGETHER: USING YOUR
KNOWLEDGE OF HEALTH FINANCE, ECONOMICS, AND
ETHICS TO INFLUENCE HEALTH AND
HEALTH CARE 191
10. Governance and Organizational Type 193
Role of the Board of Trustees 194
Types of Hospitals and Health Systems 196
Navigating Governance–Management Boundaries 200
The Relationship Between Organizational Structure and
Organizational Values 204
The Role of Board Committees 205
The Sarbanes–Oxley Act 206
11. Building Skills for Board Membership 213
Zeal, Organizational Fit, and Philanthropy 213
Types of Board Appointments 214
What a Governing Board Is Not 215
Other Types of Boards 216
Building the Skill Set for Board Membership 217
Next Steps 227
12. Applying Health Economics to Influence Health Care
Through Federal and State Policy Formation 231
Branches of Government 232
Influencing at the Committee Level 235
Timing Matters 235
Maintaining A Connection with Policy Makers to Influence
Health and Health Care 237
Ways of Influence 242
Lobbying as Official Authority to Represent A Group View 243
Grassroots Lobbying 244
How to Contact Policy Makers 244
Overcoming Impediments to Involvement 246
Learning from Distant Others 247
Learning from At-Hand Mentors 248
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viii Contents
13. Early Lessons From the COVID Pandemic and a
Look to the Future 255
14. Epilogue: Reflections on Living and Leading in a
Changing Nursing World 265
Tell Me One More Time: What Does All This Financing,
Economics, and Policy Have to Do With Nursing? 265
How to Retain and Expand on What You Have Learned 266
15. Quiz Answers 269
Appendix A Medicare Eligibility 275
Appendix B Key Concepts in Health Finance, Economics,
Policy, and Ethics: Level Setting Pre-Survey 277
Appendix C The Policy Analysis Process 281
Glossary 285
Index 291
Foreword to the
second edition
Imagine you are in a store intending to buy a shirt and your eye catches one
hanging on a display. You examine it initially from where you stand, quickly
deciding whether this shirt might work, might be worth taking a closer look.
You step closer and inspect its color, patterns, buttons, collar, stitching—the
shirt’s details that make it attractive or not—and then step back and look at
its overall appearance and gauge whether it might “look good” on you, and
whether it conveys an image that you like and want to project. Hmmm … this
shirt has possibilities. You step closer, reassess, and in affirming its appeal,
you find the tag that identifies the shirt’s size. Good, it comes in my size, now
what is its price?
Whenever we purchase items, in most cases, without being fully aware,
we usually begin by assessing its quality and then, if its quality appeals to
us, we consider its price. We take this information about the quality and ask
ourself, “At this price, is this shirt (in the example) worth it?” Am I willing to
pay this amount for the benefits (personal satisfaction) it can provide? Your
mind considers countless questions that are important to you: How often
will I wear this shirt? What pants will work with the shirt? How easily is it
to maintain? Can I wash it or does it have to go to the dry cleaner? Will it
shrink? On and on.
Another shirt catches your eye and you go through the same process.
Eventually you assemble three shirts and hang them next to each other,
focusing more directly on their comparative quality and price, and make a
decision. Suddenly, you remember that the other day you saw a similar shirt,
maybe even the same one, at a different store known for its lower prices.
You pause and wonder whether it is worth traveling to the other store and
checking to see if its price is lower. Or perhaps you think that you might find
the same shirt on the internet at a lower price. This is getting complicated.
Quality and price, along with amount of money you have (your bud-
get), are what we, as consumers, consider when making purchases, whether
it is a shirt, bicycle, camera, or insurance policy.
Employers do the same when deciding on the types and numbers of
employees to hire. Should I employ an LPN or an RN? What is the quality
of an RN compared to an LPN? Here, quality might be measured by the