Which of the following describes the 'Diagnosis Related Group (DRG)' reimbursement system?
A fixed amount each month for each enrolled patient, regardless of amount of services provided.
A flat rate per day of patient stay is used, regardless of the number or type of services provided.
A flat rate is fixed for a specific diagnosis e.g., $5000 for type 2 diabetes. Payment is based on the care given to and resources used by a "typical" patient with that disease.
A negotiated fee schedule is used and reimbursed for each health service provided.
The Correct Answer is C
The Diagnosis Related Group (DRG) system is a prospective payment framework used by insurers to categorize hospital costs and determine reimbursement levels. This system shifted the financial risk from the payer to the provider to encourage healthcare efficiency. By bundling services based on a clinical diagnosis, it incentivizes hospitals to provide cost-effective care. It is a cornerstone of modern healthcare administration and inpatient financial management.
Rationale:
A. This describes "capitation," not a DRG system. Capitation involves a per-member per-month (PMPM) payment to providers for a broad range of services. It is commonly used in Managed Care Organizations (MCOs) to manage outpatient health maintenance. DRGs, conversely, are focused on specific inpatient episodes rather than a continuous monthly fee for an enrolled population.
B. This describes a "per diem" reimbursement model. In a per diem system, the hospital is paid a fixed rate for every day the patient occupies a bed, regardless of the intensity of care. DRGs do not pay by the day; they pay a lump sum based on the diagnosis. The per diem model can actually incentivize longer hospital stays, which DRGs aim to reduce.
C. Diagnosis Related Groups (DRGs) provide a flat rate of reimbursement based on the patient's primary diagnosis and any complications. The payment is predetermined based on the resources required for a "typical" patient within that group. This forces hospitals to manage resources carefully, as they lose money if the cost of care exceeds the fixed DRG rate. It promotes standardized, efficient clinical pathways.
D. This describes a "Fee-for-Service" (FFS) model. In FFS, every individual test, procedure, and consultation is billed and reimbursed separately. This is the opposite of the DRG approach, as it may incentivize over-utilization of services to increase revenue. DRGs were created specifically as an alternative to the traditional, unbundled fee-for-service reimbursement structures.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Szasz and Hollender developed a framework to describe the dynamics of the patient-provider relationship based on the patient's level of function. These models describe how clinical authority is distributed during the therapeutic encounter. The choice of model often depends on the severity of the medical condition and the patient's ability to contribute to their own care. Understanding these models helps practitioners adapt their communication style to improve outcomes.
Rationale:
A. Activity-passivity is a model where the practitioner is entirely in control and the patient is a passive recipient of care. This occurs in emergency situations, such as when a patient is unconscious or in a coma. There is no opportunity for partnership because the patient cannot communicate. It represents the most paternalistic end of the care spectrum.
B. Guidance-cooperation occurs when the practitioner tells the patient what to do, and the patient complies with the instructions. This is common in acute infections where the doctor prescribes an antibiotic and the patient follows the regimen. While there is cooperation, it is not a true partnership, as the provider retains the majority of the decision-making power.
C. Mutual participation is the correct term for a partnership where the patient and practitioner work together as equals. This model is most effective for chronic disease management, such as diabetes, where the patient's daily choices are vital. It involves shared decision-making and recognizes the patient as an expert in their own life experience and health goals.
Correct Answer is E
Explanation
Step 1 is to calculate the molecular weight (MW) of KCl
MW = K (39) + Cl (35.5)
39 + 35.5 = 74.5
Result at this step = 74.5 g/mol
Step 2 is to convert grams (g) to milligrams (mg)
mg = 0.5 g × 1,000
0.5 × 1,000 = 500
Result at this step = 500 mg
Step 3 is to calculate the milliequivalents (mEq)
Formula: mEq = (mg × valence) ÷ MW
Valence of KCl = 1
mEq = (500 × 1) ÷ 74.5
500 × 1 = 500
(500 ÷ 74.5) = 6.7114
Result at this step = 6.7114 mEq
Step 4 is to round to the nearest whole number
6.7114 ≈ 7
Answer: 7
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