Question

Health record data serve as the basis for hospital reimbursement in the Prospective Payment System (PPS) using the ____ system in the inpatient setting and the ____ in the outpatient setting.

Answer 1

Hospital reimbursement employs the DRG system for inpatient and the APC system for outpatient settings. Policymaking in health care needs to address costs, patient quality of life, and privacy. A fee-for-service system differs from HMOs, with the latter involving managing care for a set number of patients and managing resource allocation among them.

Step-by-step explanation:

Health record data serve as the basis for hospital reimbursement in the Prospective Payment System (PPS) using the Diagnosis-Related Group (DRG) system in the inpatient setting and the Ambulatory Payment Classification (APC) in the outpatient setting. When developing policies that balance the costs of treatments and diagnoses, patient quality of life, and risks to individual privacy, three essential questions must be addressed:

1. How can we ensure equitable access to high-quality care while managing the costs associated with treatments and diagnoses?
2. What measures can be instituted to maintain or improve patient quality of life during and after treatment?
3. In what ways can we protect individual privacy and confidentiality in the context of electronic health records and data sharing?

Fee-for-service and health maintenance organizations (HMOs) are two primary methods of healthcare reimbursement. In a fee-for-service system, providers are paid based on the cost of services they provide. Conversely, HMOs reimburse providers based on the number of patients they manage, giving providers the responsibility to allocate resources efficiently among patients. This system must balance the risk of adverse selection, where insurance buyers have more information about their health risks than the insurance company, potentially leading to a discrepancy in insurance utilization and costs.