Health Care Finance, Economics, and Policy for Nurses: A Foundational Guide, Second Edition
By Betty Rambur
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. THE CONTEXT OF HEALTH CARE AND HEALTH CARE REFORM 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
- 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
- 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
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
- 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
- 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
- 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
- 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. ETHICS AND ECONOMICS IN AN AGE OF REFORM 155
- 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
- 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
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
- 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
- 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
- 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
- Early Lessons From the COVID Pandemic and a
Look to the Future 255
- 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
- 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