Week 1: Introduction: Self and Project

Because you have been in the program for a while now, you have had many opportunities to get to know others in the group fairly well. For this introduction, we’re going to shift gears a bit. During this course you will be relating many of your discussions and assignments to the project proposal you created in NR505. Please introduce yourself to the class and instructor and include the following information.

  • Describe the type of facility by which you are employed.
  • Your current position and for how long
  • Your prior experience in financial management
  • Share the PICO(T) you developed in NR505 and/or the one you will be using in your final project.
  • What led you to choose this issue/topic?

Reflection Information

Understanding how your organization is reimbursed for services depends on several components. Assess your organization and identify its care delivery system and payer mix make up. Include percentages represented by each payer group. Use the table to record your findings.

Your Name’s Healthcare Organization
Healthcare Delivery System (Type)  
Payer Mix Percentage
Managed Care  


Based on this data, discuss the assumptions that could be made about the population demographics for your institution. What influence do these variables have on the types of services offered at your facility?


  • What might your analysis tell you about the long-term health of your community?
  • What future needs might be identified?

Scholarly references to support your response are required.

Week 1: Introduction

Table of Contents

Welcome to Week 1

Access to and payment for healthcare has moved from a system of limited, sick-care driven, barter payment to one of preventive and illness care and multiple payer systems. In this week’s lesson you will explore this progress and how our healthcare financial system came to be. How payer systems influence the types of and access to healthcare services will be addressed.



Apply evidence based financial knowledge and skills within the context of holistic care principles and caring health environments. (PO 1, 2, 5) {AACN Essentials: II,III, V, VIII} {ANCC-NE-DOP: I,III}

Weekly Objectives

  • Investigate the elements of revenue management in a selected healthcare institution (CO 2) (ANCC-NE-DOP I.B.3)


Articulate the relationship between managerial and financial decision making and its implication within a culturally diverse healthcare organization and patient population. (PO 1,3) {AACN Essentials: I,II} {ANCC-NE-DOP: I, II, III}

Weekly Objectives

  • Discuss the impact of various healthcare delivery and payment systems on the population demographic being served. (CO 3,4) (ANCC-NE-DOP III.A.2)


Analyze the connection between healthcare financial systems and access to and availability of care. (PO 3) {AACN Essentials: II, IV, VI} {ANCC-NE-DOP: I, II, III}

Weekly Objectives

  • Discuss the impact of various healthcare delivery and payment systems on the population demographic being served. (CO 3,4) (ANCC-NE-DOP III.A.2)

Week 1: Reading

  • DueSep 9 by 10pm
  • PointsNone

Required Readings

Leger, J. M., & Dunham-Taylor, J. (2018). Financial management for nurse managers: Merging the heart with the dollar (4th ed.). Burlington, MA: Jones & Bartlett.

  • Chapter 1: How We Got to Where We Are
  • Chapter 2: Healthcare Stakeholders: Consumers, Providers, Payers, Suppliers, and Regulators

Marquis, B. L., & Huston, C. J. (2017). Leadership roles and management functions in nursing: Theory and application (9th ed.). Philadelphia, PA: Wolters Kluwer Health.

  • Chapter 10: Fiscal Planning
    • Healthcare Reimbursement
    • Medicare and Medicaid
    • The Prospective Payment System
    • Managed Care
    • Healthcare Reform and the Patient Protection and Affordable Care Act

Rundio, A. (2016). The nurse manager’s guide to budgeting and finance (2nd ed.). Indianapolis, IN: Sigma Theta Tau International.

  • Chapter 2: Healthcare Reimbursement

Required Articles

Rome, B., Nickitas, D., & Lawrence, D. A. (2016). The financial landscape and the implications for nursing. Nurse Leader, 14(1), 33–37. Retrieved from https://chamberlain-on-worldcat-org.chamberlainuniversity.idm.oclc.org/oclc/6010319028

Sung-Heui, B. (2016). CNE SERIES. The centers for Medicare and Medicaid services reimbursement policy and nursing-sensitive adverse patient outcomes. Nursing Economic$, 34(4), 151–181.



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Week 1: Lesson

Table of Contents

Healthcare Systems Financial Environment


How did our healthcare financial system get to where it is today? This week’s lesson provides the historical perspective on the current healthcare systems’ financial environments. Policy that led to the current payment systems, a look at what might develop in the future, and potential challenges to the system are explored.

Hi and welcome to Nursing 533 Healthcare Finance. My name is Dr. Robin Shafer, and I am going to go over, with you, the first lecture of this course. So healthcare, how did we get there from here? There’s an old saying that goes the more things change, the more they stay the same.

This trifactor of access, quality, and cost of healthcare has existed for centuries. To put this in perspective in today’s world, it is helpful to understand how our current system has evolved over time. Our current rules and regulations surrounding who gets which healthcare services or access to care. Who can deliver these services, quality of care, and how these services are paid for, cost of care is the core of health policy and it arose from improvements in areas over time, public demand, and advances in science and technology.

[BLANK_AUDIO] In the early days, healthcare was considered sick care, and long distances were traveled to access care. Treatments were provided through traditions by laypeople in the home. Licensing did not exist for physicians or nurses. And payment and cost were determined through bartering between the person providing the care and the person receiving the care.

[BLANK_AUDIO] Healthcare delivery began to shift from home to the hospital, and the hospital became not a place for dying, but a place for treatment. Advances in medical science and epidemiology led to prevention of disease and ways to contain illness. The government began to implement regulatory standards regarding the provision of healthcare.

Rules to decrease epidemics, and promotion of sanitation by the formations of the Public Health Department back in 1798, an institution of licensure for nurses and physicians. In order to understand governmental policy to improve the access to care, perhaps looking at the Institute of Medicine report that was published in 1993.

That defines access of care as the timely use of personal health services to achieve the best health outcome. Access includes care based on affordability and effectiveness and efficiency of the delivery of healthcare. The ability of the consumer to receive care based on the affordability of the services, how effective and deficient the delivery of those services is.

Our system of health care is very different than the systems in other countries, the US does not systematically provide access to care. Instead, we had a system that is built on the consumer’s ability to pay. Now, we provide care to all comers regardless of the ability to pay, but the ability to pay opens up more avenues to access and ability to choose who provides that care.

[BLANK_AUDIO] So take a moment and reflect. How does that make you feel that some have better access to care that they get to decide who provides that care, is this right, do you think it’s fair? [BLANK_AUDIO] Should everyone have equal access? According to Ledger in 2012 approximately 32.2% of our nation’s population had some form of governmental pair insurance meaning medicare, medicade, federal state policies.

Native Americans who were living Indian reservations have the public health Indian health service. And 55.1% of private citizens had insurance through employers, with their costs being shared. Now, sometimes these individuals found themselves under insured due to high deductables. [BLANK_AUDIO] So what’s left? It’s those who no insurance and are considered self paid, since the implementation of the Affordable Care Act.

The number of self pay patients has decrease from 15.7% in 2012 to 10% in 2014. This means that even though an increase number of uninsured were able to obtain coverage, there’s still 32.9 million Americans with no healthcare insurance. [BLANK_AUDIO] That is a lot of people, if you really think about it, that have no access to healthcare.

[BLANK_AUDIO] Here is a list of the contributing laws that led to where we are today. On page six of our textbook, you can find a larger overview of these laws. But it is important to understand some of the laws that got us to where we are. In 1946 the Hill-Burton Act, which was where the government Made money available to build hospitals in rural areas, thereby, increasing healthcare available to areas where there was not healthcare before.

So it increased the access, or the accessibility, and you can often tell when you’re in a Hill-Burton hospital just by the look and feel. In 1973, the Health Maintenance Organization Act was developed, and was provided federal grants to shape the way healthcare is today. In 1983 the healthcare financing administration implemented the prospective payment system, which you probably know as DRGs or diagnosis related groupings.

This implemented the set price that would be paid for care regardless of what the actual cost of that care was. In the 90s, managed care came to be, and this is a system that attempted to integrate efficiency, access and cost. Focus was placed on prevention rather than inpatient hospital care.


Use of clinical practice guidelines was developed and selected contracting whereby providers agreed to provide care for lower reimbursement levels based on population contract. In 1996 HIPPA or the Health Insurance Portability and Accountability Act came to be. Now we all generally think of HIPPA as not giving information regarding a patient if you don’t have formation to give that person information, and HIPPA was far more than that.

It established that insurers could not set limits on coverage for pre-existing conditions, guaranteed access and renewability of health insurance. And addressed the issues excluding small businesses on the basis of employee health status, and it started the implementation of the healthcare savings account. 2010 brought us the Affordable Care Act, and that leads us to where we are today.

The ACA original goal to strengthen and systematize healthcare in the US and provide new universal coverage for all. If you look at pages 15 to 21 in the Ledger and Denemteller textbook, there’s formal information on ACA. The ACA brought about bundled payments, ACOs, medical homes, value based purchasing, and the health insurance market place.

2017 brought about change and there were some changes to the Affordable Care Act. And can you think of ways this has affect how you provide care today? [BLANK_AUDIO] If we are to survive moving forward, we must look at controlling the cost of the healthcare we provide. Cost is defined as the value of all the resources used to produce the service and the resulting expenditures.

If you’re going to control cost, you have to track expenditures. In 2014, US healthcare costs grew 5.3% and averaged $9,523 per person. [BLANK_AUDIO] Sit and think about that for a second. Not every individual person costs $9,523 on average for healthcare, you yourself may only see the doctor for your routine physical.

But there are patients that you probably have in your hospital that have been there for 30, 60, 90 days. They are driving up the cost of health care, so its per person on average but not every person costs that amount. So what is quality? Quality is the degree to which health services for individuals and populations increase the likelihood of a desired outcome.

[BLANK_AUDIO] Quality truly is based on outcomes, if you control cost and track expenditures, you look at the degree to which we can increase the care for an individual. But do higher costs prevent bad outcomes? Not necessarily so, you just have to sit and think about that for a second.

Can you think of a patient that you did everything you could for and they had a bad outcome. Or a patient that perhaps you used the da Vinci Robot on and the costs were higher, but a bad outcome still occurred. So, cost does not prevent bad outcomes. [BLANK_AUDIO] Quality measures exist in all environments, some reportable quality measures that your organization may utilize are falls data, falls and falls with injury.

Healthcare acquired infections such as CAUTIs, CLABSIs, surgical site infections, ventilator associated conditions. The development of pressure ulcers, and early elective delivery. Do you use high dollar gadget s to prevent these events from happening, do they always work? [BLANK_AUDIO] So the centers for Medicare, Medicaid services developed the pay for performance strategy.

This was a system that was designed to encourage improvements in the quality of provided to the Medicare beneficiaries, the outcome will affect the payment. And it was designed to ensure that the right care for the right patient is always safe and effective, patient centered, timely, efficient, and equitable. [BLANK_AUDIO]

Here are some Never events, preventable conditions that the Hospital-Acquired Condition Reduction Program focuses on. When you look at these, these 8 events are considered never events, meaning they should never occur under any circumstance. And if they do occur Medicare will not pay for an extended stay or treatment, for a preventable complication.

Many of these events are presumed to be attributable to nursing care. That way we understand how essential it is for nurses to lead, the quality endeavour. [BLANK_AUDIO] The stakeholders, the stake holders must be taken into account when we are considering healthcare finance, cost, quality and access. Often when you think of the stakeholders you may think of the board of directors, but the stake holders are far more, so who are they?

They’re the consumers, the patients, those people receiving care. They’re the providers, the doctors and the nurses, those are who are giving care. They’re the payers, the insurance companies, those who finance the care. They’re the suppliers, those who provide materials and supplies to us the providers and they’re the regulators, the law makers, those who set the rules and regulations that must be followed for giving and paying for care.

Do the actions of one affects the actions of another, do the roles ever intermingle? [BLANK_AUDIO] Can you think of something that has happened in recent history where the actions of one hindered you from being able to provide the care that you needed to provide. And it could have ended up in a bad outcome for the consumer.

[BLANK_AUDIO] So in tripling cost, access, and quality, is it influenced or impacted by each of these stakeholders, what do you think? [BLANK_AUDIO] So, what’s next? What do you see as the thing that keeps you up at night when you think about healthcare finance? Is it the issues of access or cost, is it the aging population, is it economic issues that plague our country?

How do we as healthcare providers ensure that healthcare will exist for our children’s children? As I see it, nursing knowledge and leadership are critical to improving our healthcare system and ensuring access, cost and quality for those we serve.


Historical perspectives are usually a good place to start when examining what’s going on in current systems. How we got to where we are is important to know as we look to where we will go. Now it’s time to focus on what is currently applicable to your daily practice and how the current financial trends impact the types of services your market (stakeholders, community, and organization) demands. The discussions are a great place to explore this.

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