Please go to the following weblink:

Zimbardo, P. G., Haney, C., Banks, C., & Jaffe, D. (1973, April 8). A Pirandellian prison: The mind is a formidable jailer.  New York Times Magazine, pp. 38-60.  http://www.prisonexp.org/pdf/pirandellian.pdf

Your assignment:

1. Briefly describe the problem (or research question),  procedure (participants, methods) and results of the study.

2. Do you see any potential problems with this study, ie., methodological issues, ethical concerns, etc.?

3. Do you agree with the authors’ conclusions?  Are there other factors we should consider?

4. In your opinion, could this study be repeated today and with the same results?  Why or why not?

5. From what you know of social psychology or other pertinent psychology courses you have taken, why might this study have been important?

Asch and Conformity 

Please go to this study. http://www.wadsworth.com/psychology_d/templates/student_resources/0155060678_rathus/ps/ps18.html

Your assignment:

1. Briefly describe the problem (or research question), the hypothesis, procedure (participants, methods) and results of the study.

2. Do you see any potential problems with this study, ie., methodological issues, ethical concerns, etc.?

3. Do you agree with the authors’ conclusions? Are there other factors we should consider?

4. In your opinion, could this study be repeated today and with the same results? Why or why not?

5. From what you know of social psychology or other pertinent psychology courses you have taken, why might this study have been important?

  The Abiline Paradox:  The Management of Agreement

Whereas, most of us are familiar with the Bystander Effect and Zimbardo’s Prison Study, this study is very different for those of us who might not have had any courses in organizational psychology.  As you will see many of the concepts we have learned early on in introductory psychology, social psychology and other courses come into play in this case.  See what you think.

Please click on the following link and enter your last name and ID number.

Harvey, J. B. (1974). The Abilene Paradox: The management of agreement.Organizational Dynamics, 3 (1), 63 – 80. doi: 10.1016/0090-2616(74)90005-9 http://ezproxy.umuc.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=bth&AN=5140990&site=eds-live&scope=site

Your assignment:

I found the list of objectives for this article on page 66 would be a good starting point for our discussion.  You need not discuss all of these issues in depth, but try to hit the high points of 4 or 5 if you can. I have rephrased these for you below.   Also, please relate some of the concepts you have learned in your other courses whenever you can.

1) What is the Abilene paradox?  Describe some of the the symptoms of organizations caught in the paradox.

2) Tell us about one of the case studies that Harvey (1974) describes on pages 67-69.

3) Harvey discusses 5 factors when analyzing the paradox.  Discuss at least two of these and their importance in the paradox.

4) On page 73, Harvey discusses several terms that describe the risk factors of his model (A Possible Abilene Bypass). Discuss several of these as they relate to his model and to your understanding of these terms in social psychology.

5) How would someone go about diagnosing the paradox?  What suggestions does Harvey make?

6) What are his recommendations for coping with the paradox?

Your thoughts, and comments, please.  

Leiby Kletzy’s Abduction and Homicide

Read the case at:  http://sciencecases.lib.buffalo.edu/cs/files/social_reaction.pdf

First, provide a short description of the case.

Then, identify and explain at least 4 social psychological principles at work in this case.

For some ideas, see the worksheets following the case.

Bystander Intervention  

Please go to this study. You sill need to enter your last name and ID number and then download the study.

Darley, J. M., & Latané, B. (1968). Bystander intervention in emergencies: Diffusion of responsibility.  Journal of Personality & Social Psychology, 8 (4), 377-383. http://ezproxy.umuc.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=16645191&site=eds-live&scope=site

Your assignment:

1. Briefly describe the problem (or research question), the hypothesis, procedure (participants, methods) and results of the study.

2. Do you see any potential problems with this study, ie., methodological issues, ethical concerns, etc.?

3. Do you agree with the authors’ conclusions? Are there other factors we should consider?

4. In your opinion, could this study be repeated today and with the same results? Why or why not?

5. From what you know of social psychology or other pertinent psychology courses you have taken, why might this study have been important?

Darley, J. M., & Latané, B. (1968). Bystander intervention in emergencies: Diffusion of responsibility.  Journal of Personality & Social Psychology, 8 (4), 377-383.  http://ezproxy.umuc.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=16645191&site=eds-live&scope=site

STUDY……

BYSTANDER INTERVENTION IN EMERGENCIES: DIFFUSION OF RESPONSIBILITY3 JOHN M. BARLEY New York University BIBB LATANfi Columbia University Ss overheard an epileptic seizure. They believed either that they alone heard the emergency, or that 1 or 4 unseen others were also present. As predicted the presence of other bystanders reduced the individual’s feelings of personal responsibility and lowered his speed of reporting (p < .01). In groups of size 3, males reported no faster than females, and females reported no slower when the 1 other bystander was a male rather than a female. In general, personality and background measures were not predictive of helping. Bystander inaction in real-life emergencies is often explained by “apathy,” “alienation,” and “anomie.” This experiment suggests that the explanation may lie more in the bystander’s response to other observers than in his indifference to the victim. Several years ago, a young woman was stabbed to death in the middle of a street in a residential section of New York City. Although such murders are not entirely routine, the incident received little public attention until several weeks later when the New York Times disclosed another side to the case: at least 38 witnesses had observed the attack— and none had even attempted to intervene. Although the attacker took more than half an hour to kill Kitty Genovese, not one of the 38 people who watched from the safety of their own apartments came out to assist her. Not one even lifted the telephone to call the police (Rosenthal, 1964). Preachers, professors, and news commentators sought the reasons for such apparently conscienceless and inhumane lack of intervention. Their conclusions ranged from “moral decay,” to “dehumanization produced by the urban environment,” to “alienation,” “anomie,” and “existential despair.” An analysis of the situation, however, suggests that factors other than apathy and indifference were involved. A person witnessing an emergency situation, particularly such a frightening and 1 This research was supported in part by National Science Foundation Grants GS1238 and GS1239. Susan Darley contributed materially to the design of the experiment and ran the subjects, and she and Thomas Moriarty analyzed the data. Richard Nisbett, Susan Millman, Andrew Gordon, and Norma Neiman helped in preparing the tape recordings. dangerous one as a stabbing, is in conflict. There are obvious humanitarian norms about helping the victim, but there are also rational and irrational fears about what might happen to a person who does intervene (Milgram & Hollander, 1964). “I didn’t want to get involved,” is a familiar comment, and behind it lies fears of physical harm, public embarrassment, involvement with police procedures, lost work days and jobs, and other unknown dangers. In certain circumstances, the norms favoring intervention may be weakened, leading bystanders to resolve the conflict in the direction of nonintervention. One of these circumstances may be the presence of other onlookers. For example, in the case above, each observer, by seeing lights and figures in other apartment house windows, knew that others were also watching. However, there was no way to tell how the other observers were reacting. These two facts provide several reasons why any individual may have delayed or failed to help. The responsibility for helping was diffused among the observers; there was also diffusion of any potential blame for not taking action; and finally, it was possible that somebody, unperceived, had already initiated helping action. When only one bystander is present in an emergency, if help is to come, it must come from him. Although he may choose to ignore it (out of concern for his personal safety, or desires “not to get involved”), any pres- 377 ,178 JOHN M. DARLEY AND BIBB LATANTC sure to intervene focuses uniquely on him. When there are several observers present, however, the pressures to intervene do not focus on any one of the observers; instead the responsibility for intervention is shared among all the onlookers and is not unique to any one. As a result, no one helps. A second possibility is that potential blame may be diffused. However much we may wish to think that an individual’s moral behavior is divorced from considerations of personal punishment or reward, there is both theory and evidence to the contrary (Aronfreed, 1964; Miller & Bollard, 1941, Whiting & Child, 19S3). It is perfectly reasonable to assume that, under circumstances of group responsibility for a punishable act, the punishment or blame that accrues to any one individual is often slight or nonexistent. Finally, if others are known to be present, but their behavior cannot be closely observed, any one bystander can assume that one of the other observers is already taking action to end the emergency. Therefore, his own intervention would be only redundant—perhaps harmfully or confusingly so. Thus, given the presence of other onlookers whose behavior cannot be observed, any given bystander can rationalize his own inaction by convincing himself that “somebody else must be doing something.” These considerations lead to the hypothesis that the more bystanders to an emergency, the less likely, or the more slowly, any one bystander will intervene to provide aid. To test this propostion it would be necessary to create a situation in which a realistic “emergency” could plausibly occur. Each subject should also be blocked from communicating with others to prevent his getting information about their behavior during the emergency. Finally, the experimental situation should allow for the assessment of the speed and frequency of the subjects’ reaction to the emergency. The experiment reported below attempted to fulfill these conditions. PROCEDURE Overview. A college student arrived in the laboratory and was ushered into an individual room from which a communication system would enable him to talk to the other participants. It was explained to him that he was to take part in a discussion about personal problems associated with college life and that the discussion would be held over the intercom system, rather than face-to-face, in order to avoid embarrassment by preserving the anonymity of the subjects. During the course of the discussion, one of the other subjects underwent what appeared to be a very serious nervous seizure similar to epilepsy. During the fit it was impossible for the subject to talk to the other discussants or to find out what, if anything, they were doing about the emergency. The dependent variable was the speed with which the subjects reported the emergency to the experimenter. The major independent variable was the number of people the subject thought to be in the discussion group. Subjects. Fifty-nine female and thirteen male students in introductory psychology courses at New York University were contacted to take part in an unspecified experiment as part of a class requirement. Method. Upon arriving for the experiment, the subject found himself in a long corridor with doors opening off it to several small rooms. An experimental assistant met him, took him to one of the rooms, and seated him at a table. After filling out a background information form, the subject was given a pair of headphones with an attached microphone and was told to listen for instructions. Over the intercom, the experimenter explained that he was interested in learning about the kinds of personal problems faced by normal college students in a high pressure, urban environment. He said that to avoid possible embarrassment about discussing personal problems with strangers several precautions had been taken. First, subjects would remain anonymous, which was why they had been placed in individual rooms rather than face-to-face. (The actual reason for this was to allow tape recorder simulation of the other subjects and the emergency.) Second, since the discussion might be inhibited by the presence of outside listeners, the experimenter would not listen to the initial discussion, but would get the subject’s reactions later, by questionnaire. (The real purpose of this was to remove the obviously responsible experimenter from the scene of the emergency.) The subjects were told that since the experimenter was not present, it was necessary to impose some organization. Each person would talk in turn, presenting his problems to the group. Next, each person in turn would comment on what the others had said, and finally, there would be a free discussion. A mechanical switching device would regulate this discussion sequence and each subject’s microphone would be on for about 2 minutes. While any microphone was on, all other microphones would be off. Only one subject, therefore, could be heard over the network at any given time. The subjects were thus led to realize when they later heard the seizure that only the victim’s microphone was on and that there was no way of determining what any of the other witnesses were doing, nor of discussing the event and its possible solution with the others. When these instructions had been given, the discussion began. BYSTANDER INTERVENTION IN EMERGENCIES 379 In the discussion, the future victim spoke first, saying that he found it difficult to get adjusted to New York City and lo his studies. Very hesitantly, and with obvious embarrassment, he mentioned that he was prone to seizures, particularly when studying hard or taking exams. The other people, including the real subject, took their turns and discussed similar problems (minus, of course, the proneness to seizures). The naive subject talked last in the series, after the last prerecorded voice was played.2 When it was again the victim’s turn to talk, he made a few relatively calm comments, and then, growing increasingly louder and incoherent, he continued: I-er-um-I think I-I necd-er-if-if could-er-er-somebody er-er-er-er-er-er-er give me a liltle-er-give me a little help here because-er-I-er-I’m-er-erh-h-having a-a-a real problcm-er-right now and I-er-if somebody could help me out it would-it would-er-er s-s-sure be-sure be good . . . becausecr-there-er-cr-a cause I-er-I-uh-I’ve got a-a one of the-er-sei er-cr-things coming on and-and-and I could really-er-use some help so if somebody would-er-give me a little h-help-uh-er-er-er-er-er c-could somebody-er-er-help-er-uh-uh-uh (choking sounds). . . . I’m gonna die-er-er-I’m . . . gonna die-er-help-er-er-seizure-er-[chokes, then quiet]. The experimenter began timing the speed of the real subject’s response at the beginning of the victim’s speech. Informed judges listening to the tape have estimated that the victim’s increasingly louder and more disconnected ramblings clearly represented a breakdown about 70 seconds after the signal for the victim’s second speech. The victim’s speech was abruptly cut off 125 seconds after this signal, which could be interpreted by the subject as indicating that the time allotted for that speaker had elapsed and the switching circuits had switched away from him. Times reported in the results are measured from the start of the fit. Group size variable. The major independent variable of the study was the number of other people that the subject believed also heard the fit. By the assistant’s comments before the experiment, and also by the number of voices heard to speak in the first round of the group discussion, the subject was led lo believe that the discussion group was one of three sizes: either a two-person group (consisting of a person who would later have a fit and the real subject), a three-person group (consisting of the victim, the real subject, and one confederate voice), or a six-person group (consisting of the victim, the real subject, and four confederate voices). All the confederates’ voices were tape-recorded. Variations in group composition. Varying the kind as well as the number of bystanders present at an 2 To test whether the order in which the subjects spoke in the first discussion round significantly affected the subjects’ speed of report, the order in which the subjects spoke was varied (in the sixperson group). This had no significant or noticeable effect on the speed of the subjects’ reports. emergency should also vary the amount of responsibility felt by any single bystander. To test this, several variations of the three-person group were run. In one three-person condition, the taped bystander voice was that of a female, in another a male, and in the third a male who said that he was a premedical student who occasionally worked in the emergency wards at Bellevue hospital. In the above conditions, the subjects were female college students. In a final condition males drawn from the same introductory psychology subject pool were tested in a three-person female-bystander condition. Time to help. The major dependent variable was the time elapsed from the start of the victim’s fit until the subject left her experimental cubicle. When the subject left her room, she saw the experimental assistant seated at the end of the hall, and invariably went to the assistant. If 6 minutes elapsed without the subject having emerged from her room, the experiment was terminated. As soon as the subject reported the emergency, or after 6 minutes had elapsed, the experimental assistant disclosed the true nature of the experiment, and dealt with any emotions aroused in the subject. Finally the subject filled out a questionnaire concerning her thoughts and feelings during the emergency, and completed scales of Machiavellianism, anomie, and authoritarianism (Christie, 1964), a social desirability scale (Crowne & Marlowe, 1964), a social responsibility scale (Daniels & Berkowitz, 1964), and reported vital statistics and socioeconomic data. RESULTS Plausibility of Manipulation Judging by the subjects’ nervousness when they reported the fit to the experimenter, by their surprise when they discovered that the fit was simulated, and by comments they made during the fit (when they thought their microphones were off), one can conclude that almost all of the subjects perceived the fit as real. There were two exceptions in different experimental conditions, and the data for these subjects were dropped from the analysis. Effect of Group Size on Helping The number of bystanders that the subject perceived to be present had a major effect on the likelihood with which she would report the emergency (Table 1). Eighty-five percent of the subjects who thought they alone knew of the victim’s plight reported the seizure before the victim was cut off, only 31% of those who thought four other bystanders were present did so. 380 JOHN M. DARLF.V AND BIBB LATANIR TABLE 1 ‘KCTS 01? GROUPS SIZE ON LIKELIHOOD AND SPEED or RESPONSE Group size 2 (5 & victim) 3 (S, victim, & 1 other) 6 (.9, victim, & 4 others) N 13 26 13 % responding by end of fit 85 62 31 Time in sec. 52 93 166 Speed score .87 .72 .51 Note.—p value of diffciences: x 2 = 7.91, p < .02; 7” = 8.09, p < .01, for speed scores. Every one of the subjects in the twoperson groups, but only 62% of the subjects in the six-person groups, ever reported the emergency. The cumulative distributions of response times for groups of different perceived size (Figure 1) indicates that, by any point in time, more subjects from the two-person groups had responded than from the three-person groups, and more from the three-person groups than from the six-person groups. Ninety-five percent of all the subjects who ever responded did so within the first half of the time available to them. No subject who had not reported within 3 minutes after the fit ever did so. The shape of these distributions suggest that had the experiment been allowed to run for a considerably longer time, few additional subjects would have responded. Speed of Response To achieve a more detailed analysis of the results, each subject’s time score was transloo 12o 16O 2oo 24O 28O Seconds from Beginning of Fit FIG. 1. Cumulative distributions of helping responses. formed into a “speed” score by taking the reciprocal of the response time in seconds and multiplying by 100. The effect of this transformation was to deemphasize differences between longer time scores, thus reducing the contribution to the results of the arbitrary 6-minute limit on scores. A high speed score indicates a fast response. An analysis of variance indicates that the effect of group size is highly significant (/> < .01). Duncan multiple-range tests indicate that all but the two- and three-person groups differ significantly from one another (#<.OS). Victim’s Likelihood of Being Helped An individual subject is less likely to respond if he thinks that others are present. But what of the victim? Is the inhibition of the response of each individual strong enough to counteract the fact that with five onlookers there are five times as many people available to help? From the data of this experiment, it is possible mathematically to create hypothetical groups with one, two, or five observers.8 The calculations indicate that the victim is about equally likely to get help from one bystander as from two. The victim is considerably more likely to have gotten help from one or two observers than from five during the first minute of the fit. For instance, by 45 seconds after the start of the fit, the victim’s chances of having been helped by the single bystanders were about 50%, compared to none in the five observer condition. After the first minute, the likelihood of getting help from at least one person is high in all three conditions. Effect of Group Composition on Helping the Victim Several variations of the three-person group were run. In one pair of variations, the female subject thought the other bystander was either male or female; in another, she thought the other bystander was a premedical student who worked in an emergency ward at Bellevue hospital. As Table 2 shows, the 8 The formula for the probability that at least one person will help by a given time is 1 —(1—P) ” where n is the number of observers and P is the probability of a single individual (who thinks he is one of n observers) helping by that time. BYSTANDER INTERVENTION IN EMERGENCIES 381 TABLE 2 EFI’ECTS OF GROUP COMPOSITION ON LIKKLIHOOH AND SPEED OF RESPONSE” Group composition Female S, male other Female S, female other Female 5, male medic other Male S, female other N 13 13 5 13 % responding by end of fit 62 62 100 69 Time in sec. 94 92 60 110 Speed score 74 71 77 68 » Three-person group, mule victim. variations in sex and medical competence of the other bystander had no important or detectable affect on speed of response. Subjects responded equally frequently and fast whether the other bystander was female, male, or medically experienced. Sex of the Subject and Speed of Response Coping with emergencies is often thought to be the duty of males, especially when females are present, but there was no evidence that this was the case in this study. Male subjects responded to the emergency with almost exactly the same speed as did females (Table 2). Reasons for Intervention or Nonintervention After the debriefing at the end of the experiment each subject was given a 15-item checklist and asked to check those thoughts which had “crossed your mind when you heard Subject 1 calling for help.” Whatever the condition, each subject checked very few thoughts, and there were no significant differences in number or kind of thoughts in the different experimental groups. The only thoughts checked by more than a few subjects were “I didn’t know what to do” (18 out of 65 subjects), “I thought it must be some sort of fake” (20 out of 65), and “I didn’t know exactly what was happening” (26 out of 65). It is possible that subjects were ashamed to report socially undesirable rationalizations, or, since the subjects checked the list after the true nature of the experiment had been explained to them, their memories might have been blurred. It is our impression, however, that most subjects checked few reasons because they had few coherent thoughts during the fit. We asked all subjects whether the presence or absence of other bystanders had entered their minds during the time that they were hearing the fit. Subjects in the three- and six-person groups reported that they were aware that other people were present, but they felt that this made no difference to their own behavior. Individual Difference Correlates of Speed of Report The correlations between speed of report and various individual differences on the personality and background measures were obtained by normalizing the distribution of report speeds within each experimental condition and pooling these scores across all conditions (« = 62-65). Personality measures showed no important or significant correlations with speed of reporting the emergency. In fact, only one of the 16 individual difference measures, the size of the community in which the subject grew up, correlated (r = -.26, p < .05) with the speed of helping. DISCUSSION Subjects, whether or not they intervened, believed the fit to be genuine and serious. “My God, he’s having a fit,” many subjects said to themselves (and were overheard via their microphones) at the onset of the fit. Others gasped or simply said “Oh.” Several of the male subjects swore. One subject said to herself, “It’s just my kind of luck, something has to happen to me!” Several subjects spoke aloud of their confusion about what course of action to take, “Oh God, what should I do?” When those subjects who intervened stepped out of their rooms, they found the experimental assistant down the hall. With some uncertainty, but without panic, they reported the situation. “Hey, I think Number 1 is very sick. He’s having a fit or something.” After ostensibly checking on the situation, the experimenter returned to report that “everything is under control.” The subjects accepted these assurances with obvious relief. Subjects who failed to report the emergency showed few signs of the apathy and 382 JOHN M. BARLEY AND BIBB LATANTC indifference thought to characterize “unresponsive bystanders.” When the experimenter entered her room to terminate the situation, the subject often asked if the victim was “all right.” “Is he being taken care of?” “He’s all right isn’t he?” Many of these subjects showed physical signs of nervousness; they often had trembling hands and sweating palms. If anything, they seemed more emotionally aroused than did the subjects who reported the emergency. Why, then, didn’t they respond? It is our impression that nonintervening subjects had not decided not to respond. Rather they were still in a state of indecision and conflict concerning whether to respond or not. The emotional behavior of these nonresponding subjects was a sign of their continuing conflict, a conflict that other subjects resolved by responding. The fit created a conflict situation of the avoidance-avoidance type. On the one hand, subjects worried about the guilt and shame they would feel if they did not help the person in distress. On the other hand, they were concerned not to make fools of themselves by overreacting, not to ruin the ongoing experiment by leaving their intercom, and not to destroy the anonymous nature of the situation which the experimenter had earlier stressed as important. For subjects in the two-person condition, the obvious distress of the victim and his need for help were so important that their conflict was easily resolved. For the subjects who knew there were other bystanders present, the cost of not helping was reduced and the conflict they were in more acute. Caught between the two negative alternatives of letting the victim continue to suffer or the costs of rushing in to help, the nonresponding bystanders vacillated between them rather than choosing not to respond. This distinction may be academic for the victim, since he got no help in either case, but it is an extremely important one for arriving at an understanding of the causes of bystanders’ failures to help. Although the subjects experienced stress and conflict during the experiment, their general reactions to it were highly positive. On a questionnaire administered after the experimenter had discussed the nature and purpose of the experiment, every single subject found the experiment either “interesting” or “very interesting” and was willing to participate in similar experiments in the future. All subjects felt they understood what the experiment was about and indicated that they thought the deceptions were necessary and justified. All but one felt they were better informed about the nature of psychological research in general. Male subjects reported the emergency no faster than did females. These results (or lack of them) seem to conflict with the Berkowitz, Klanderman, and Harris (1964) finding that males tend to assume more responsibility and take more initiative than females in giving help to dependent others. Also, females reacted equally fast when the other bystander was another female, a male, or even a person practiced in dealing with medical emergencies. The ineffectiveness of these manipulations of group composition cannot be explained by general insensitivity of the speed measure, since the group-size variable had a marked effect on report speed. It might be helpful in understanding this lack of difference to distinguish two general classes of intervention in emergency situations: direct and reportorial. Direct intervention (breaking up a fight, extinguishing a fire, swimming out to save a drowner) often requires skill, knowledge, or physical power. It may involve danger. American cultural norms and Berkowitz’s results seem to suggest that males are more responsible than females for this kind of direct intervention. A second way of dealing with an emergency is to report it to someone qualified to handle it, such as the police. For this kind of intervention, there seem to be no norms requiring male action. In the present study, subjects clearly intended to report the emergency rather than take direct action. For such indirect intervention, sex or medical competence does not appear to affect one’s qualifications or responsibilities. Anybody, male or female, medically trained or not, can find the experimenter. In this study, no subject was able to tell how the other subjects reacted to the fit. (Indeed, there were no other subjects actually present.) The effects of group size on BYSTANDER INTERVENTION IN EMERGENCIES 383 speed of helping, therefore, are due simply to the perceived presence of others rather than to the influence of their actions. This means that the experimental situation is unlike emergencies, such as a fire, in which bystanders interact with each other. It is, however, similar to emergencies, such as the Genovese murder, in which spectators knew others were also watching but were prevented by walls between them from communication that might have counteracted the diffusion of responsibility. The present results create serious difficulties for one class of commonly given explanations for the failure of bystanders to intervene in actual emergencies, those involving apathy or indifference. These explanations generally assert that people who fail to intervene are somehow different in kind from the rest of us, that they ar

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                                    NURS6630 Final Exam (2018): Walden University

QUESTION 1 

What will the PMHNP most likely prescribe to a patient with psychotic aggression who needs to manage the top-down cortical control and the excessive drive from striatal hyperactivity? 

A. Stimulants B. Antidepressants C. Antipsychotics D. SSRIs 

QUESTION 2 

The PMHNP is selecting a medication treatment option for a patient who is exhibiting psychotic behaviors with poor impulse control and aggression. Of the available treatments, which can help temper some of the adverse effects or symptoms that are normally caused by D2 antagonism? 

A. First-generation, conventional antipsychotics B. First-generation, atypical antipsychotics C. Second-generation, conventional antipsychotics D. Second-generation, atypical antipsychotics 

QUESTION 3 

The PMHNP is discussing dopamine D2 receptor occupancy and its association with aggressive behaviors in patients with the student. Why does the PMHNP prescribe a standard dose of atypical antipsychotics? 

A. The doses are based on achieving 100% D2 receptor occupancy. B. The doses are based on achieving a minimum of 80% D2 receptor occupancy. C. The doses are based on achieving 60% D2 receptor occupancy. D. None of the above. 

QUESTION 4 

Why does the PMHNP avoid prescribing clozapine (Clozaril) as a first-line treatment to the patient with psychosis and aggression? 

A. There is too high a risk of serious adverse side effects. B. It can exaggerate the psychotic symptoms. C. Clozapine (Clozaril) should not be used as high-dose monotherapy. D. There is no documentation that clozapine (Clozaril) is effective for patients who are violent. 

QUESTION 5 

The PMHNP is caring for a patient on risperidone (Risperdal). Which action made by the PMHNP exhibits proper care for this patient? 

A. Explaining to the patient that there are no risks of EPS B. Prescribing the patient 12 mg/dail C. Titrating the dose by increasing it every 5–7 days D. Writing a prescription for a higher dose of oral risperidone (Risperdal) to achieve high D2 receptor occupancy 

QUESTION 6 

The PMHNP wants to prescribe Mr. Barber a mood stabilizer that will target aggressive and impulsive symptoms by decreasing dopaminergic neurotransmission. Which mood stabilizer will the PMHNP select? A. Lithium (Lithane) B. Phenytoin (Dilantin) C. Valproate (Depakote) D. Topiramate (Topamax) 

QUESTION 7 

The parents of a 7-year-old patient with ADHD are concerned about the effects of stimulants on their child. The parents prefer to start pharmacological treatment with a non-stimulant. Which medication will the PMHNP will most likely prescribe? 

A. Strattera B. Concerta C. Daytrana D. Adderall 

QUESTION 8

8 The PMHNP understands that slow-dose extended release stimulants are most appropriate for which patient with ADHD? 

A. 8-year-old patient B. 24-year-old patient C. 55-year-old patient D. 82-year-old patient 

QUESTION 9 

A patient is prescribed D-methylphenidate, 10-mg extended-release capsules. What should the PMHNP include when discussing the side effects with the patient? 

A. The formulation can have delayed actions when taken with food. B. Sedation can be a common side effect of the drug. C. The medication can affect your blood pressure. D. This drug does not cause any dependency. 

QUESTION 10 

The PMHNP is teaching parents about their child’s new prescription for Ritalin. What will the PMHNP include in the teaching? 

A. The second dose should be taken at lunch. B. There are no risks for insomnia. C. There is only one daily dose, to be taken in the morning. D. There will be continued effects into the evening. 

QUESTION 11 

A young patient is prescribed Vyvanse. During the follow-up appointment, which comment made by the patient makes the PMHNP think that the dosing is being done incorrectly? 

A. “I take my pill at breakfast.” B. “I am unable to fall asleep at night.” C. “I feel okay all day long.” D. “I am not taking my pill at lunch.” 

QUESTION 12 

A 14-year-old patient is prescribed Strattera and asks when the medicine should be taken. What does the PMHNP understand regarding the drug’s dosing profile? 

A. The patient should take the medication at lunch. B. The patient will have one or two doses a day. C. The patient will take a pill every 17 hours. D. The dosing should be done in the morning and at night. 

QUESTION 13 

The PMHNP is meeting with the parents of an 8-year-old patient who is receiving an initial prescription for D-amphetamine. The PMHNP demonstrates appropriate prescribing practices when she prescribes the following dose: 

A. The child will be prescribed 2.5 mg. B. The child will be prescribed a 10-mg tablet. C. The child’s dose will increase by 2.5 mg every other week. D. The child will take 10–40 mg, daily. 

QUESTION 14 

A patient is being prescribed bupropion and is concerned about the side effects. What will the PMHNP tell the patient regarding bupropion? 

A. Weight gain is not unusual. B. Sedation may be common. C. It can cause cardiac arrhythmias. D. It may amplify fatigue. 

QUESTION 15 

Which patient will receive a lower dose of guanfacine? 

A. Patient who has congestive heart failure B. Patient who has cerebrovascular disease C. Patient who is pregnant D. Patient with kidney disease 

QUESTION 16 

An 18-year-old female with a history of frequent headaches and a mood disorder is prescribed topiramate (Topamax), 25 mg by mouth daily. The PMHNP understands that this medication is effective in treating which condition(s) in this patient? 

A. Migraines B. Bipolar disorder and depression C. Pregnancy-induced depression D. Upper back pain 

QUESTION 17 

The PMHNP is treating a patient for fibromyalgia and is considering prescribing milnacipran (Savella). When prescribing this medication, which action is the PMHNP likely to choose? 

A. Monitor liver function every 6 months for a year and then yearly thereafter. B. Monitor monthly weight. C. Split the daily dose into two doses after the first day. D. Monitor for occult blood in the stool. 

QUESTION 18 

The PMHNP is assessing a patient she has been treating with the diagnosis of chronic pain. During the assessment, the patient states that he has recently been having trouble getting to sleep and staying asleep. Based on this information, what action is the PMHNP most likely to take? 

A. Order hydroxyzine (Vistaril), 50 mg PRN or as needed B. Order zolpidem (Ambien), 5mg at bedtime C. Order melatonin, 5mg at bedtime D. Order quetiapine (Seroquel), 150 mg at bedtime 

QUESTION 19 

The PMHNP is assessing a female patient who has been taking lamotrigine (Lamictal) for migraine prophylaxis. After discovering that the patient has reached the maximum dose of this medication, the PMHNP decides to change the patient’s medication to zonisamide (Zonegran). In addition to evaluating this patient’s day-to-day activities, what should the PMHNP ensure that this patient understands? 

A. Monthly blood levels must be drawn. B. ECG monitoring must be done once every 3 months. C. White blood cell count must be monitored weekly. D. This medication has unwanted side effects such as sedation, lack of coordination, and drowsiness. 

QUESTION 20 

A patient recovering from shingles presents with tenderness and sensitivity to the upper back. He states it is bothersome to put a shirt on most days. This patient has end stage renal disease (ESRD) and is scheduled to have hemodialysis tomorrow but states that he does not know how he can lie in a recliner for 3 hours feeling this uncomfortable. What will be the PMHNP’s priority? 

A. Order herpes simplex virus (HSV) antibody testing B. Order a blood urea nitrogen (BUN) and creatinine STAT C. Prescribe lidocaine 5% D. Prescribe hydromorphone (Dilaudid) 2mg 

QUESTION 21 

The PMHNP prescribed a patient lamotrigine (Lamictal), 25 mg by mouth daily, for nerve pain 6 months ago. The patient suddenly presents to the office with the complaint that the medication is no longer working and complains of increased pain. What action will the PMHNP most likely take? 

A. Increase the dose of lamotrigine (Lamictal) to 25 mg twice daily. B. Ask if the patient has been taking the medication as prescribed. C. Order gabapentin (Neurontin), 100 mg three times a day, because lamotrigine (Lamictal) is no longer working for this patient. D. Order a complete blood count (CBC) to assess for an infection. 

QUESTION 22 

An elderly woman with a history of Alzheimer’s disease, coronary artery disease, and myocardial infarction had a fall at home 3 months ago that resulted in her receiving an open reduction internal fixation. While assessing this patient, the PMHNP is made aware that the patient continues to experience mild to moderate pain. What is the PMHNP most likely to do? 

A. Order an X-ray because it is possible that she dislocated her hip. B. Order ibuprofen (Motrin) because she may need long-term treatment and chronic pain is not uncommon. C. Order naproxen (Naprosyn) because she may have arthritis and chronic pain is not uncommon. D. Order Morphine and physical therapy. 

QUESTION 23 

The PMHNP is assessing a 49-year-old male with a history of depression, post-traumatic stress disorder (PTSD), alcoholism with malnutrition, diabetes mellitus type 2, and hypertension. His physical assessment is unremarkable with the exception of peripheral edema bilaterally to his lower extremities and a chief complaint of pain with numbness and tingling to each leg 5/10. The PMHNP starts this patient on a low dose of doxepin (Sinequan). What is the next action that must be taken by the PMHNP? 

A. Orders liver function tests. B. Educate the patient on avoiding grapefruits when taking this medication. C. Encourage this patient to keep fluids to 1500 ml/day until the swelling subsides. D. Order a BUN/Creatinine test. 

QUESTION 24 

The PMHNP is evaluating a 30-year-old female patient who states that she notices pain and a drastic change in mood before the start of her menstrual cycle. The patient states that she has tried diet and lifestyle changes but nothing has worked. What will the PMHNP most likely do? A. Prescribe Estrin FE 24 birth control B. Prescribe ibuprofen (Motrin), 800 mg every 8 hours as needed for pain C. Prescribe desvenlafaxine (Pristiq), 50 mg daily D. Prescribe risperidone (Risperdal), 2 mg TID 

QUESTION 25 

A patient with chronic back pain has been prescribed a serotonin-norepinephrine reuptake inhibitor (SNRI). How does the PMHNP describe the action of SNRIs on the inhibition of pain to the patient? 

A. “The SNRI can increase noradrenergic neurotransmission in the descending spinal pathway to the dorsal horn.” B. “The SNRI can decrease noradrenergic neurotransmission in the descending spinal pathway to the dorsal horn.” C. “The SNRI can reduce brain atrophy by slowing the gray matter loss in the dorsolateral prefrontal cortex.” D. “The SNRI can increase neurotransmission to descending neurons.” 

QUESTION 26 

A patient with fibromyalgia and major depression needs to be treated for symptoms of pain. Which is the PMHNP most likely to prescribe for this patient? 

Venlafaxine (Effexor) 

Duloxetine (Cymbalta) 

Clozapine (Clozaril) 

Phenytoin (Dilantin) 

QUESTION 27 

The PMHNP prescribes gabapentin (Neurontin) for a patient’s chronic pain. How does the PMHNP anticipate the drug to work? 

A. It will bind to the alpha-2-delta ligand subunit of voltage-sensitive calcium channels. B. It will induce synaptic changes, including sprouting. C. It will act on the presynaptic neuron to trigger sodium influx. D. It will inhibit activity of dorsal horn neurons to suppress body input from reaching the brain. 

QUESTION 28 

Mrs. Rosen is a 49-year-old patient who is experiencing fibro-fog. What does the PMHNP prescribe for Mrs. Rosen to improve this condition? A. Venlafaxine (Effexor) B. Armodafinil (Nuvigil) C. Bupropion (Wellbutrin) D. All of the above 

QUESTION 29 

The PMHNP is caring for a patient with fibromyalgia. Which second-line treatment does the PMHNP select that may be effective for managing this patient’s pain?

A. Methylphenidate (Ritalin) B. Viloxazine (Vivalan) C. Imipramine (Tofranil) D. Bupropion (Wellbutrin 

QUESTION 30 

The PMHNP is attempting to treat a patient’s chronic pain by having the agent bind the open channel conformation of VSCCs to block those channels with a “use-dependent” form of inhibition. Which agent will the PMHNP most likely select? 

A. Pregabalin (Lyrica) B. Duloxetine (Cymbalta) C. Modafinil (Provigil) D. Atomoxetine (Strattera) 

QUESTION 31 

A patient with irritable bowel syndrome reports chronic stomach pain. The PMHNP wants to prescribe the patient an agent that will cause irrelevant nociceptive inputs from the pain to be ignored and no longer perceived as painful. Which drug will the PMHNP prescribe? 

A. Pregabalin (Lyrica) B. Gabapentin (Neurontin) C. Duloxetine (Cymbalta) D. B and C 

QUESTION 32 

The PMHNP wants to use a symptom-based approach to treating a patient with fibromyalgia. How does the PMHNP go about treating this patient? 

A. Prescribing the patient an agent that ignores the painful symptoms by initiating a reaction known as “fibro-fog” B. Targeting the patient’s symptoms with anticonvulsants that inhibit gray matter loss in the dorsolateral prefrontal cortex C. Matching the patient’s symptoms with the malfunctioning brain circuits and neurotransmitters that might mediate those symptoms D. None of the above 

QUESTION 33 

The PMHNP is working with the student to care for a patient with diabetic peripheral neuropathic pain. The student asks the PMHNP why SSRIs are not consistently useful in treating this particular patient’s pain. What is the best response by the PMHNP? 

A. “SSRIs only increase norepinephrine levels.” B. “SSRIs only increase serotonin levels.” C. “SSRIs increase serotonin and norepinephrine levels.” D. “SSRIs do not increase serotonin or norepinephrine levels.” 

QUESTION 34 

A patient with gambling disorder and no other psychiatric comorbidities is being treated with pharmacological agents. Which drug is the PMHNP most likely to prescribe? 

A. Antipsychotics B. Lithium C. SSRI D. Naltrexone 

QUESTION 35 

Kevin is an adolescent who has been diagnosed with kleptomania. His parents are interested in seeking pharmacological treatment. What does the PMHNP tell the parents regarding his treatment options? 

A. “Naltrexone may be an appropriate option to discuss.” B. “There are many medicine options that treat kleptomania.” C. “Kevin may need to be prescribed antipsychotics to treat this illness.” D. “Lithium has proven effective for treating kleptomania.” 

QUESTION 36 

Which statement best describes a pharmacological approach to treating patients for impulsive aggression? 

A. Anticonvulsant mood stabilizers can eradicate limbic irritability. B. Atypical antipsychotics can increase subcortical dopaminergic stimulation. C. Stimulants can be used to decrease frontal inhibition. D. Opioid antagonists can be used to reduce drive. 

QUESTION 37 

A patient with hypersexual disorder is being assessed for possible pharmacologic treatment. Why does the PMHNP prescribe an antiandrogen for this patient? 

A. It will prevent feelings of euphoria. B. It will amplify impulse control. C. It will block testosterone. D. It will redirect the patient to think about other things. 

QUESTION 38 

Mrs. Kenner is concerned that her teenage daughter spends too much time on the Internet. She inquires about possible treatments for her daughter’s addiction. Which response by the PMHNP demonstrates understanding of pharmacologic approaches for compulsive disorders? 

A. “Compulsive Internet use can be treated similarly to how we treat people with substance use disorders.” B. “Internet addiction is treated with drugs that help block the tension/arousal state your daughter experiences.” C. “When it comes to Internet addiction, we prefer to treat patients with pharmaceuticals rather than psychosocial methods.” D. “There are no evidence-based treatments for Internet addiction, but there are behavioral therapies your daughter can try.” 

QUESTION 39 

Mr. Peterson is meeting with the PMHNP to discuss healthier dietary habits. With a BMI of 33, Mr. Peterson is obese and needs to modify his food intake. “Sometimes I think I’m addicted to food the way some people are addicted to drugs,” he says. Which statement best describes the neurobiological parallels between food and drug addiction? 

A. There is decreased activation of the prefrontal cortex. B. There is increased sensation of the reactive reward system. C. There is reduced activation of regions that process palatability. D. There are amplified reward circuits that activate upon consumption. 

QUESTION 40 

The PMHNP is caring for a patient who reports excessive arousal at nighttime. What could the PMHNP use for a time-limited duration to shift the patient’s brain from a hyperactive state to a sleep state? 

A. Histamine 2 receptor antagonist B. Benzodiazepines C. Stimulants D. Caffeine 

QUESTION 41 

The PMHNP is caring for a patient who experiences too much overstimulation and anxiety during daytime hours. The patient agrees to a pharmacological treatment but states, “I don’t want to feel sedated or drowsy from the medicine.” Which decision made by the PMHNP demonstrates proper knowledge of this patient’s symptoms and appropriate treatment options? 

A. Avoiding prescribing the patient a drug that blocks H1 receptors B. Prescribing the patient a drug that acts on H2 receptors C. Stopping the patient from taking medicine that unblocks H1 receptors D.None of the above 

QUESTION 42 

The PMHNP is performing a quality assurance peer review of the chart of another PMHNP. Upon review, the PMHNP reviews the chart of an older adult patient in long-term care facility who has chronic insomnia. The chart indicates that the patient has been receiving hypnotics on a nightly basis. What does the PMHNP find problematic about this documentation? 

A. Older adult patients are contraindicated to take hypnotics. B. Hypnotics have prolonged half-lives that can cause drug accumulation in the elderly. C. Hypnotics have short half-lives that render themselves ineffective for older adults. D. Hypnotics are not effective for “symptomatically masking” chronic insomnia in the elderly. 

QUESTION 43 

The PMHNP is caring for a patient with chronic insomnia who is worried about pharmacological treatment because the patient does not want to experience dependence. Which pharmacological treatment approach will the PMHNP likely select for this patient for a limited duration, while searching and correcting the underlying pathology associated with the insomnia? 

A. Serotonergic hypnotics B. Antihistamines C. Benzodiazepine hypnotics D. Non-benzodiazepine hypnotics 

QUESTION 44 

The PMHNP is caring for a patient with chronic insomnia who would benefit from taking hypnotics. The PMHNP wants to prescribe the patient a drug with an ultra-short half-life (1–3 hours). Which drug will the PMHNP prescribe? 

A. Flurazepam (Dalmane) B. Estazolam (ProSom) C. Triazolam (Halcion) D. Zolpidem CR (Ambien) 

QUESTION 45 

The PMHNP is attempting to treat a patient’s chronic insomnia and wishes to start with an initial prescription that has a half-life of approximately 1–2 hours. What is the most appropriate prescription for the PMHNP to make? 

A. Triazolam (Halcion) B. Quazepam (Doral) C. Temazepam (Restoril) D. Flurazepam (Dalmane) 

QUESTION 46 

A patient with chronic insomnia asks the PMHNP if they can first try an over-the-counter (OTC) medication before one that needs to be prescribed to help the patient sleep. Which is the best response by the PMHNP? 

A. “There are no over-the-counter medications that will help you sleep.” B. “You can choose from one of the five benzo hypnotics that are approved in the United States.” C. “You will need to ask the pharmacist for a non-benzodiazepine medicine.” D. “You can get melatonin over the counter, which will help with sleep onset.” 

QUESTION 47 

A patient with chronic insomnia and depression is taking trazodone (Oleptro) but complains of feeling drowsy during the day. What can the PMHNP do to reduce the drug’s daytime sedating effects? 

A. Prescribe the patient an antihistamine to reverse the sedating effects B. Increasing the patient’s dose and administer it first thing in the morning C. Give the medicine at night and lower the dose D. None of the above 

QUESTION 48 

The PMHNP is teaching a patient with a sleep disorder about taking diphenhydramine (Benadryl). The patient is concerned about the side effects of the drug. What can the PMHNP teach the patient about this treatment approach? 

A. “It can cause diarrhea.” B. “It can cause blurred vision.” C. “It can cause increased salivation.” D. “It can cause heightened cognitive effects.” 

QUESTION 49 

Parents of a 12-year-old boy want to consider attention deficit hyperactivity disorder (ADHD) medication for their son. Which medication would the PMHNP start? 

Methylphenidate Amphetamine salts Atomoxetine All of the above could potentially treat their son’s symptoms. 

QUESTION 50

An adult patient presents with a history of alcohol addiction and attention deficit hyperactivity disorder (ADHD). Given these comorbidities, the PMHNP determines which of the following medications may be the best treatment option? 

A. Methylphenidate (Ritalin, Concerta) B. Amphetamine C. Atomoxetine (Strattera) D. Fluoxetine (Prozac) 

QUESTION 51 

An 8-year-old patient presents with severe hyperactivity, described as “ants in his pants.” Based on self-report from the patient, his parents, and his teacher; attention deficit hyperactivity disorder (ADHD) is suspected. What medication is the PMNHP most likely to prescribe? 

A. Methylphenidate (Ritalin, Concerta) B. Clonidine (Catapres) C. Bupropion (Wellbutrin) D. Desipramine (Norpramin) 

QUESTION 52 

A 9-year-old female patient presents with symptoms of both attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder. In evaluating her symptoms, the PMHNP determines that which of the following medications may be beneficial in augmenting stimulant medication? 

A. Bupropion (Wellbutrin) B. Methylphenidate (Ritalin, Concerta) C. Guanfacine ER (Intuniv) D. Atomoxetine (Strattera) 

QUESTION 53 

A PMHNP supervisor is discussing with a nursing student how stimulants and noradrenergic agents assist with ADHD symptoms. What is the appropriate response? 

A. They both increase signal strength output dopamine (DA) and norepinephrine (NE). B. Dopamine (DA) and norepinephrine (NE) are increased in the prefrontal cortex. C. Noradrenergic agents correct reductions in dopamine (DA) in the reward pathway leading to increased ability to maintain attention to repetitive or boring tasks and resist distractions. D. All of the above. 

QUESTION 54 

A 43-year-old male patient is seeking clarification about treating attention deficit hyperactivity disorder (ADHD) in adults and how it differs from treating children, since his son is on medication to treat ADHD. The PMHNP conveys a major difference is which of the following? 

A. Stimulant prescription is more common in adults. B. Comorbid conditions are more common in children, impacting the use of stimulants in children. C. Atomoxetine (Strattera) use is not advised in children. D. Comorbidities are more common in adults, impacting the prescription of additional agents. 

QUESTION 55 

A 26-year-old female patient with nicotine dependence and a history of anxiety presents with symptoms of attention deficit hyperactivity disorder (ADHD). Based on the assessment, what does the PMHNP consider? 

A. ADHD is often not the focus of treatment in adults with comorbid conditions. B. ADHD should always be treated first when comorbid conditions exist. C. Nicotine has no reported impact on ADHD symptoms. D. Symptoms are often easy to treat with stimulants, given the lack of comorbidity with other conditions. 

QUESTION 56 

Which of the following is a true statement regarding the use of stimulants to treat attention deficit hyperactivity disorder (ADHD)? 

A. In adults with both ADHD and anxiety, treating the anxiety with selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), or benzodiazepines and the ADHD with stimulants is most effective in treating both conditions. B. Signal strength output is increased by dialing up the release of dopamine (DA) and norepinephrine (NE). C. In conditions where excessive DA activation is present, such as psychosis or mania, comorbid ADHD should never be treated with stimulants. D. High dose and pulsatile delivery of stimulants that are short acting are preferred to treat ADHD. 

QUESTION 57 

The PMHNP is providing a workshop for pediatric nurses, and a question is posed about noradrenergic agents to treat ADHD. Which of the following noradrenergic agents have norepinephrine reuptake inhibitor (NRI) properties that can treat ADHD? 

A. Desipramine (Norpramin) B. Methylphenidate (Ritalin, Concerta) C. Atomoxetine (Strattera) D. Both “A” & “C” E. “C” only 

QUESTION 58 

A 71-year-old male patient comes to an appointment with his 65-year-old wife. They are both having concerns related to her memory and ability to recognize faces. The PMNHP is considering prescribing memantine (Namenda) based on the following symptoms: 

A. Amnesia, aphasia, apnea B. Aphasia, apraxia, diplopia C. Amnesia, apraxia, agnosia D. Aphasia, agnosia, arthralgia 

QUESTION 59 

The PMHNP evaluates a patient presenting with symptoms of dementia. Before the PMHNP considers treatment options, the patient must be assessed for other possible causes of dementia. Which of the following answers addresses both possible other causes of dementia and a rational treatment option for Dementia? 

A. Possible other causes: hypothyroidism, Cushing’s syndrome, multiple sclerosis Possible treatment option: memantine B. Possible other causes: hypothyroidism, adrenal insufficiency, hyperparathyroidism Possible treatment option: donepezil C. Possible other causes: hypothyroidism, adrenal insufficiency, niacin deficiency Possible treatment option: risperidone D. Possible other causes: hypothyroidism, Cushing’s syndrome, lupus erythematosus Possible treatment option: donepezil 

QUESTION 60 

A group of nursing students seeks further clarification from the PMHNP on how cholinesterase inhibitors are beneficial for Alzheimer’s disease patients. What is the appropriate response? 

A. Acetylcholine (ACh) destruction is inhibited by blocking the enzyme acetylcholinesterase. B. Effectiveness of these agents occurs in all stages of Alzheimer’s disease. C. By increasing acetylcholine, the decline in some patients may be less rapid. D. Both “A” & “C.” 

QUESTION 61 

The PMHNP is assessing a patient who presents with elevated levels of brain amyloid as noted by positron emission tomography (PET). What other factors will the PMHNP consider before prescribing medication for this patient, and what medication would the PMHNP want to avoid given these other factors? 

A. ApoE4 genotype and avoid antihistamines if possible B. Type 2 diabetes and avoid olanzapine C. Anxiety and avoid methylphenidate D. Both “A” & “B” 

QUESTION 62 

A 72-year-old male patient is in the early stages of Alzheimer’s disease. The PMHNP determines that improving memory is a key consideration in selecting a medication. Which of the following would be an appropriate choice? 

A. Rivastigmine (Exelon) B. Donepezil (Aricept) C. Galantamine (Razadyne) D. All of the above 

QUESTION 63 

A 63-year-old patient presents with the following symptoms. The PMHNP determines which set of symptoms warrant prescribing a medication? Select the answer that is matched with an appropriate treatment. 

A. Reduced ability to remember names is most problematic, and an appropriate treatment option is memantine. B. Impairment in the ability to learn and retain new information is most problematic, and an appropriate treatment option would be donepezil. C. Reduced ability to find the correct word is most problematic, and an appropriate treatment option would be memantine. D. Reduced ability to remember where objects are most problematic, and an appropriate treatment option would be donepezil. 

QUESTION 64 

A 75-year-old male patient diagnosed with Alzheimer’s disease presents with agitation and aggressive behavior. The PMHNP determines which of the following to be the best treatment option? 

A. Immunotherapy B. Donepezil (Aricept) C. Haloperidol (Haldol) D. Citalopram (Celexa) or Escitalopram (Lexapro) 

QUESTION 65 

The PMHNP has been asked to provide an in-service training to include attention to the use of antipsychotics to treat Alzheimer’s. What does the PMHNP convey to staff? 

A. The use of antipsychotics may cause increased cardiovascular events and mortality. B. A good option in treating agitation and psychosis in Alzheimer’s patients is haloperidol (Haldol). C. Antipsychotics are often used as “chemical straightjackets” to over-tranquilize patients. D. Both “A” & “C.” 

QUESTION 66 

An 80-year-old female patient diagnosed with Stage II Alzheimer’s has a history of irritable bowel syndrome. Which cholinergic drug may be the best choice for treatment given the patient’s gastrointestinal problems? 

A. Donepezil (Aricept) B. Rivastigmine (Exelon) C. Memantine (Namenda) D. All of the above 

QUESTION 67 

The PMHNP understands that bupropion (Wellbutrin) is an effective way to assist patients with smoking cessation. Why is this medication effective for these patients? 

A. Bupropion (Wellbutrin) releases the dopamine that the patient would normally receive through smoking. B. Bupropion (Wellbutrin) assists patients with their cravings by changing the way that tobacco tastes. C. Bupropion (Wellbutrin) blocks dopamine reuptake, enabling more availability of dopamine. D. Bupropion (Wellbutrin) works on the mesolimbic neurons to increase the availability of dopamine. 

QUESTION 68 

Naltrexone (Revia), an opioid antagonist, is a medication that is used for which of the following conditions? 

A. Alcoholism B. Chronic pain C. Abuse of inhalants D. Mild to moderate heroin withdrawal 

QUESTION 69 

A patient addicted to heroin is receiving treatment for detoxification. He begins to experience tachycardia, tremors, and diaphoresis. What medication will the PMHNP prescribe for this patient? 

A. Phenobarbital (Luminal) B. Methadone (Dolophine) C. Naloxone (Narcan) D. Clonidine (Catapres) 

QUESTION 70 

A patient diagnosed with obsessive compulsive disorder has been taking a high-dose SSRI and is participating in therapy twice a week. He reports an inability to carry out responsibilities due to consistent interferences of his obsessions and compulsions. The PMHNP knows that the next step would be which of the following? 

A. Decrease his SSRI and add buspirone (Buspar). B. Decrease his SSRI and add an MAOI. C. Decrease his SSRI steadily until it can be discontinued then try an antipsychotic to manage his symptoms. D. Keep his SSRI dosage the same and add a low-dose TCA. 

QUESTION 71 

The PMHNP is assessing a patient who will be receiving phentermine (Adipex-P)/topiramate (Topamax) (Qsymia). Which of the following conditions/diseases will require further evaluation before this medication can be prescribed

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To complete this assignment, you will need to access to the following databases: CINAHL, MEDLINE, Cochrane Library, and the Joanna Briggs Institute. I

know you can do this work, so don’t go short cut and mess it up. Research each heading and complete.

See the article I attached. Find more articles to complete to complete this work.

As a writer, you should first write a good introduction for each topic briefly say the story you about to tell, the subjects you going to talk about. 

You then tall this story by each subject.

You summarize all the story for conclusion

Don’t do lazy work no beginning , no end. Don’t be repetitive to fill the page 

Don’t copy old work

Don’t give me somebody’s work. I will know.

Grammer has got to improve. I end up deleting all work in the process of editing. Most time work below college level. I mean it. And sometimes it can be accepted at masters level.

1: Distinguish selected factors affecting U.S. healthcare delivery systems and organizations 

Introduction: Find good article

 1.

2.

3.

2: Examine factors affecting healthcare finance and payment systems 

Introduction

 1.

2.

3.

 3: Evaluate selected healthcare policy models and frameworks 

Intrduction: Find good article

Suptopics

 1.

2.

3.

4

5

6

7

4: Formulate strategies for coalition building and health advocacy 

Intrduction: Find good article

 1.

2.

3.

5: Synthesize selected policy analyses affecting advanced practice nursing

Intrduction: Find good article

 1.

2.

3.

Inclusion of all story work

Examples

Increased health insurance coverage

Payer pressures to reduce costs

• Medicare physician services payments are based on fee schedule (Resource Based Relative Value Scale, or RBRVS).

Change from “reasonable cost” to prospective payment system based on diagnosis related groups for hospital inpatient services begins under Medicare

Interview conducted and issues highlighted. Find issues in the policy or issues you can associate to the yellow highlighted in box

High staffing turnover

Diabetics patients are noncompliant   with medication is more predominant

The   facility denies any safety concerns

There is high staff turnover

No diabetics education protocol or   policy in 

place for the old and newly diagnosed   diabetics 

Facility   denies and sentinel event

Yes

The   relationship is good. Staff are not expected to take short cuts

Management   is open for suggestions or improvements

Examples:

Staff   members are not mistreated

Electronic health Record is not in   use, No plans for one. Still using   paper medical records

No   further issues

Diabetic education for noncompliant   diabetics patients

Very good role model

The nurse leader will be good preceptor

Transformational leadership

yes

Category

Points

%

Description

Introduction

Introduces the   interview, purpose of the interview, and provides rationale for engaged   interview process.

To determine existing   practice problem within the organization

Description   of Policy Issue

Please discuss the organizational assessment and how   you decided upon this particular policy. Also include any subtopics regarding   selected healthcare policy issue. Use examples from the interview that   support your assertions and relevant examples from your practice situation.

Presentation of Policy Analysis

Include eight subtopics regarding selected   healthcare policy analysis pathway. Summarize your subtopics using examples   from the interview that support your assertions as well as relevant examples   from your practice situation.

Conclusion

An effective conclusion identifies the main ideas   and major conclusions from the body of your report. Minor details are left   out. Summarize the benefits of the selected policy analysis to nursing   practice.

Clarity of writing

Use of standard English grammar and sentence   structure. No spelling errors or typographical errors. Organized around the   required components using appropriate headers.

APA   format

All information taken from another source,   even if summarized, must be appropriately cited in the report (including   citation of interview) and listed in the references using APA (6th   ed.) format:

1. Document setup

2. Title and reference pages

3. Citations in the text and references.

Total:

250

100%

A quality report will   meet or exceed all of the above requirements.

There are more than 9000 billing codes for individual procedures and units of care. But there is not a single billing code for patient adherence or improvement, or for helping patients stay well.”

Clayton M. Christensen

Health care financing in the United States is fragmented, complex, and the most costly in the world. The Affordable Care Act (ACA) of 2010 takes some steps to reshape how health care is paid for, but its primary purpose is to extend insurance coverage to approximately 30 million uninsured Americans through private insurance regulation, expansion of pubic insurance programs, and creation of health insurance marketplaces to foster competition in the private health insurance market. As the ACA is implemented, making health insurance more affordable and containing the rise in health care costs are significant ongoing policy challenges in system transformation. This chapter will provide an overview of the current system of health care financing in the United States, including the impact of the ACA.

Historical Perspectives on Health Care Financing

Understanding today’s complex and often confusing approaches to financing health care requires an examination of the nation’s values and historical context. Some dominant values underpin the U.S. political and economic systems. The United States has a long history of individualism, an emphasis on freedom to choose alternatives and an aversion to large-scale government intervention into the private realm. Compared with other developed nations with capitalist economies, social programs have been the exception rather than the rule and have been adopted primarily during times of great need or social and political upheaval. Examples of these exceptions include the passage of the Social Security Act of 1935 and the passage of Medicare and Medicaid in 1965.

Because health care in the United States had its origins in the private sector market, not government, and because of the growing political power of physicians, hospitals, and insurance companies, the degree to which government should be involved in health care remains controversial. Other developed capitalist countries, such as Canada, the United Kingdom, France, Germany, and Switzerland, view health care as a social good that should be available to all. In contrast, the United States has viewed health care as a market-based commodity, readily available to those who can pay for it but not available universally to all people. With its capitalist orientation and politically powerful financial stakeholders, the United States has been resistant to significant health care reform, especially as it relates to expanding access to affordable health insurance.

The debate over the role of government in social programs intensified in the decades after the Great Depression. Although the Social Security Act of 1935 brought sweeping social welfare legislation, providing for Social Security payments, workman’s compensation, welfare assistance for the poor, and certain public health, maternal, and child health services, it did not provide for health care insurance coverage for all Americans. Also, during the decade following the Great Depression, nonprofit Blue Cross and Blue Shield (BC/BS) emerged as a private 173insurance plan to cover hospital and physician care. The idea that people should pay for their medical care before they actually got sick, through insurance, ensured some level of security for both providers and consumers of medical services. The creation of insurance plans effectively defused a strong political movement toward legislating a broader, compulsory government-run health insurance plan at the time (Starr, 1982). After a failed attempt by President Truman in the late 1940s to provide Americans with a national health plan, no progress occurred on this issue until the 1960s, when Medicare and Medicaid were enacted.

BC/BS dominated the health insurance industry until the 1950s, when for-profit commercial insurance companies entered the market and were able to compete with BC/BS by holding down costs through their practice of excluding sick (with preexisting conditions) people from insurance coverage. Over time, the distinction between BC/BS and commercial insurance companies became increasingly blurred as BC/BS began to offer competitive for-profit plans (Kovner, Knickman, & Weisfeld, 2011. In the 1960s, the United States enjoyed relative prosperity, along with a burgeoning social conscience, and an appetite for change that led to a heightened concern for the poor and older adults and the impact of catastrophic illness. In response, Medicaid and Medicare, two separate but related programs, were created in 1965 by amendments to the Social Security Act. Medicare is a federal government-administered health insurance pro­gram for the disabled and those over 65 years (Kaiser Family Foundation [KFF], 2014c), and Medicaid, until recently, has been a state and federal government-administered health insurance pro­gram for low-income people, who are in certain categories, such as pregnant women with children.

Government Programs

Current Public/Federal Funding for Health Care in the United States

In the United States, no single public entity oversees or controls the entire health care system, making the payment for and delivery of health care complex, inefficient, and expensive. Instead, the system is composed of many public and private programs that form interrelated parts at the federal, state, and local levels. The public funding systems, which include Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), the U.S. Department of Veterans Affairs (VA), and the Defense Health Program (TRICARE) for military personnel, their families, military retirees, and some others, continue to represent a larger and larger proportion of health care spending. Other examples of federal programs are the Indian Health Service, which covers American Indians and Alaskan Natives, and the Federal Employees Health Benefits (FEHB) Program, which covers all federal employees unless excluded by law or regulation.

Federal health expenditures for these programs totaled $731.6 billion or 26% of all health care expenditures in 2012 (Martin et al., 2014). Medicare outlays were $572.5 billion in 2012 and accounted for 20% of all national health care expenditures with Medicare Advantage (a Medicare-managed care program provided by insurance plans that can be chosen by beneficiaries instead of the traditional Medicare program) growing most rapidly (Martin et al., 2014). Medicaid outlays in 2012 were $412.2 billion and accounted for 15% of total national health care expenditures, and its spending growth also decelerated that year (Martin et al., 2014).

Medicare

Before the enactment of Medicare in 1965, older adults were more likely to be uninsured and more likely to be impoverished by excessive health care costs. Half of older Americans had no health insurance; but by 2000, 96% of seniors had health care coverage through Medicare (Federal Interagency Forum on Age-Related Statistics, 2000).

Medicare had a beneficial effect on the health of older adults by facilitating access to care and medical technology, and, in 2006, prescription drug coverage helped improve the economic status of older adults. The percentage of persons over age 65 years living below the poverty line decreased from 35% in 1959 (when older adults had the highest poverty rate of the population) to 9% in 2012 (U.S. Census Bureau, 2014).

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Americans are eligible for Medicare Part A at age 65 years, the age for Social Security eligibility, or sooner, if they are determined to be disabled. Medicare Part A accounted for 31% of benefit spending in 2012 and covers 52 million Americans. Medicare Part A covers hospital and related costs and is financed through payroll deduction to the Hospital Insurance Trust Fund at the payroll tax rate of 2.9% of earnings paid by employers and employees (1.45% each) (KFF, 2014a). Medicare Part B, which accounted for approximately one third of benefit spending in 2012, covers 80% of the fees for phy­sician services, outpatient medical services and supplies, home care, durable medical equipment, laboratory services, physical and occupational therapy, and outpatient mental health services. Part B is financed through subscriber premiums and general revenue funding as well as cost-sharing with beneficiaries.

Medicare Part C, or the Medicare Advantage Program, through which beneficiaries can enroll in a private health plan and also receive some extra services such as vision or hearing services, accounted for 23% of benefit spending in 2012 and had more than 14.1 million enrollees, or 28% of all Medicare beneficiaries in 2013 (Medpac, 2013). Medicare Advantage enrollment has been increasing and is up 30% since 2010 (KFF, 2014a). Extra payments that the federal government has made to private Medicare Advantage Plans are due to be phased out by the ACA, raising concerns that insurers will drop their Medicare Advantage Plans as a result.

Medicare Part D is a voluntary, subsidized outpatient prescription drug plan with additional subsidies for low- and modest-income individuals. It accounted for 10% of benefit spending in 2012 and enrolled 39 million beneficiaries in 2013 (KFF, 2014a, 2014b). Figure 18-1 presents Medicare benefit payments by type of service in 2012 (KFF, 2014a). Medicare Part D is financed through general revenues and beneficiary premiums as well as state payments for recipients who get both Medicare and Medicaid, also known as “dual eligibles” (KFF, 2014b). The ACA phases out the Medicare Part D “donut hole,” a period of noncoverage for prescription drugs that left many seniors unable to pay out-of-pocket for their medications.

FIGURE 18-1 Medicare benefit payments by type of service, 2012. (From Kaiser Family Foundation. [2014]. Retrieved from kff.org/medicare/fact-sheet/medicare-spending-and-financing-fact-sheet/.)

The ACA authorized that certified nurse midwives (CNMs) be reimbursed at 100% of the physician payment rate. Other advanced practice registered nurses (APRNs), including nurse practitioners (NPs), are paid 85% of the physician rate 175for the same services. In addition, Medicare will not pay for home care or hospice services unless they are ordered by a physician. And, unfortunately, the ACA required physician orders for durable medical equipment for Medicare beneficiaries.

Medicaid

Medicaid is the public insurance program jointly funded by state and federal governments but administered by individual states under guidelines of the federal government. Medicaid is a means-tested program because eligibility is determined by financial status. Before changes by the ACA, only low-income people within certain categories, such as recipients of Supplemental Social Security Income (SSI), families receiving Temporary Assistance to Needy Families (TANF), and children and pregnant women whose family income is at or below 133% of the poverty level were eligible. To qualify for federal Medicaid matching grants, a state must provide a minimum set of benefits, including hospitalization, physician care, laboratory services, radiology studies, prenatal care, and preventive services; nursing home and home health care; and medically necessary transportation. Medicaid programs are also required to pay the Medicare pre­miums, deductibles, and copayments for certain low-income persons who are eligible for both programs. Medicaid is increasingly becoming a long-term care financing program of last resort for older adults in nursing homes. Many older adults have to spend down their life savings to become low income and be eligible for Medicaid. Family and pediatric NPs and CNMs are also required to be reimbursed under federal Medicaid rules if, in accordance with state regulations, they are legally authorized to provide Medicaid-covered services.

In keeping with its goal to expand health insurance coverage to more Americans, the ACA expands eligibility for the Medicaid program to any legal resident under the age of 65 years with an income up to 138% of the federal poverty level. The intent of the health reform law was to have one eligibility standard across all states and eliminate eligibility by specific categories (Commonwealth Fund, 2011; Rosenbaum, 2011). The federal government has agreed to pay for nearly all the expansion costs to insure more low-income people. The U.S. Supreme Court, however, struck down the mandate to expand Medicaid and ruled that states could decide whether or not to expand the program. Figure 18-2 indicates that as of April 2014, 27 states had decided to expand Medicaid, 5 are still debating this, and 19 are not moving forward (KFF, 2014d). States that decide to opt out of the expansion can follow old federal guidelines for eligibility, leaving wide disparities in health insurance coverage between states and leaving uninsured large proportions of the population below 138% of the poverty level. Of the states that have opted out of expansion, all have Republican political leaders explicit in their opposition to the ACA, although Republican Governor Jan Brewer of Arizona pushed her state to expand Medicaid in 2013 so that 300,000 more poor and disabled residents of the state would have coverage (Schwartz, 2013). In many of the nonparticipating states, physicians, nurses, hospitals, and other health care organizations and stakeholders are pressuring their state governments to expand Medicaid as a way to improve access to health care for more low-income people.

FIGURE 18-2 State Medicaid expansion, November 2014. (From FamiliesUSA. [2014]. Retrieved fromfamiliesusa.org/product/50-state-look-medicaid-expansion; and Kaiser Family Foundation. [2014]. Retrieved fromkff.org/medicaid/fact-sheet/a-closer-look-at-the-impact-of-state-decisions-not-to-expand-medicaid-on-coverage-for-uninsured-adults/.)

CHIP was created in 1997 to help cover uninsured children whose families were not eligible for Medicaid. It has been funded through state and federal funds, but states set their own eligibility standards. The ACA commits the federal government to paying most of its costs, beginning in 2015, up to 100%. It also requires states to maintain their eligibility standards for CHIP (Emanuel, 2014). CHIP will be reauthorized in 2015, and, because it is expected that many more children will have gained coverage through family health insurance plans, debate is expected over the role of the program. CHIP is enrolling a record number of children now estimated to be one third of all children in the United States. Advocates want to maintain these high child health insurance rates until the ACA is fully implemented and full coverage for children under the provisions of the ACA is assured.

State Health Care Financing

State governments not only administer and partially fund some public insurance programs such as Medicaid and CHIP but they are also responsible for individual state public health programs. 176The definition of public health as compared with other types of health programs is not always well understood. The mission of public health as defined by the Institute of Medicine (IOM) is to ensure conditions in which people can be healthy (IOM, 1988). Whereas medicine focuses on the individual patient, public health focuses on whole populations. Medical care for the individual patient is associated with payment by health insurance, but population-based public health programs are funded by local, county, state revenues, often combined with grants from the federal government in areas such as maternal and child health, obesity prevention, HIV/AIDS, substance abuse, and environmental health. Even with a greater federal role in health care through the ACA, states will continue to have a major responsibility for the regulation of health insurance, health care providers and professionals, and public health activities.

Reduction of budgets for public health programs during times of fiscal constraint has resulted in the resurgence of infectious diseases such as tuberculosis and sexually transmitted diseases in some communities. A series of natural disasters such as tornados also brought to light gaps in the public health system, especially the ability to respond, for example, to mass casualty events. Although the ACA authorized $15 billion for the creation of a Prevention and Public Health Fund to invest in public health and disease prevention, Congress reduced by one third the amount of funding mandated by the law in 2012 and President Obama signed the legislation to pay for other initiatives (Health Policy Brief, 2012).

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Local/County Level

Similar to state governments, local and county governments in many states also have the responsibility of protecting public health. Some provide indigent care by funding and running public hospitals and clinics, such as New York City’s Health and Hospitals Corporation and Chicago’s Cook County Hospital. Although receiving a subsidy from their local government, these hospitals, which have served primarily poor patients and those without health insurance, have gotten significant special payments, especially from Medicare to serve these populations. These disproportionate share hospital (DSH) payments are being gradually reduced under the ACA because it is presumed that eventually, under the ACA, many more people will gain health insurance coverage. Because public hospitals and clinics are so dependent on public funds, their budgets are historically squeezed during times of fiscal restraint by local, state, and federal governments, making them vulnerable to long-term sustainability. In fact, many public health hospitals have closed, and in many parts of the country, the populations they have served have been absorbed by other types of hospital providers (KFF, 2013).

The Private Health Insurance and Delivery Systems

The U.S. health care system has been predominantly a private one that operates more like a business and, more or less, according to free market principles. Private health insurance has been the dominant payer and, for most Americans, it is obtained as a benefit of employment in the form of group health insurance. However, until the passage of the ACA employers have had no obligation to provide employee health insurance, leaving many Americans uninsured or underinsured, especially those working in lower-wage jobs. As private health insurance premiums have risen, employers asked employees to pay for a greater percentage of their insurance premium, and to enroll in plans that required more cost-sharing in the form of copayment, deductibles, and coinsurance. Approximately 15% of insured Americans have purchased their health insurance from the nongroup individual insurance market. Typically, these plans were more expensive and insurers in all but a few states had been able to deny insurance to applicants with preexisting medical conditions, until the practice of discrimination based on medical history was outlawed by the ACA in 2010. Because private insurers are regulated by individual states, there are wide disparities in coverage from state to state, as private insurers are powerful political stakeholders who resist attempts at state or federal regulations to make insurance more accessible and affordable. Whereas private health insurance will continue to be a cornerstone of the U.S. health care financing system, public insurers such as Medicare and Medicaid are paying for an increasing percentage of health care costs.

It should be noted that health insurance is regulated by the states. Some states now mandate that NPs be considered primary care providers and eligible for credentialing and payment by private insurers. But there is wide variation in the extent to which APRNs are included in insurers’ provider panels. This variation can be seen among states, among insurers within a given state, and among the plans offered by an insurer (Brassard, 2014).

Most care in the United States is provided by nonprofit or for-profit hospitals and health care systems and private insurance plans (Truffer et al., 2010). Pharmaceutical companies, suppliers of health care technology, and the various service industries that support the health care system in the United States are part of what has been called the medical industrial complex (Meyers, 1970), and there is little government regulation of these industries. Although the private delivery system is dependent on payment from private insurers as well as government insurers, it has usually been resistant to government-directed efforts to expand access to care or cost-containment measures. Well-financed special interest groups representing industry stakeholders have had a great deal of influence over the political process at both the state and federal levels. For example, the medical device industry is lobbying Congress hard to repeal or reduce the medical device tax that the ACA levied to help pay 178for the expansion of insurance coverage under the health care law and has gained significant support in Congress (Kramer & Kasselheim, 2013).

The Problem of Continually Rising Health Care Costs

From the 1970s to the present, continually rising insurance premiums and health care delivery costs have strained government budgets, become a costly expense to businesses that offer health insurance to their employees, and put health care increasingly out of reach for individuals and families. Figure 18-3 depicts the annual percentage change in national health expenditures by selected sources of funds, 1960 to 2012 (KFF, 2014e).

FIGURE 18-3 Annual percentage change in national health expenditures, by selected sources of funds, 1960 to 2012. (From Kaiser Family Foundation. [2014]. Retrieved fromkaiserfamilyfoundation.files.wordpress.com/2014/02/annual-percent-change-in-national-health-expenditures-by-selected-sources-of-funds-1960-2012-healthcosts.png.)

Stakeholders in small and large businesses, government, organized labor, health care providers, and consumer groups have convened over the years to tackle the problem of rising health care costs, with little lasting success. Although a range of strategies was employed to curb rising health care costs over those 40 years, health care expenditures as a percentage of the gross domestic product (GDP) increased steadily over that time. Although multiple factors are responsible for rising health care costs as a percentage of GDP, the key one is that, unlike other capitalist democracies, the federal and state governments have little, if any, role in regulating what can be charged for health care services and supplies. Prices are largely negotiated between health insurances and providers, resulting in wide variances in prices for similar or exact services, largely based on the market clout of providers to negotiate higher prices. Other contributing factors to high health care costs include the complex administrative systems of insurers and providers, the use of expensive medical technology and medical specialists, and 179the incentive in fee-for-service reimbursement for providers to increase their volume of services and provide unnecessary health care. Consumers have also lacked knowledge of the actual cost of their care, leading to an inability of the market to accurately respond to cost and differential health care prices by region, type of hospital, or health care facility.

Future costs will also be impacted by the aging of the population and increasing number of people with complex chronic illness who use a disproportionately high percentage of the health care dollars. For example, from 1977 to 2007, a very stable 5% of the population who had complex chronic illness accounted for nearly 50% of the health care expenditures (KFF, 2010; Stanton, 2006), despite efforts to control costs among this population. In 2009, the costliest 5% of beneficiaries accounted for 39% of all Medicare fee-for-service spending. The least costly 50% of beneficiaries accounted for 5% of all spending (Medpac, 2013). The majority of those in the high-expenditure group are not older adults but rather those with complex chronic illnesses (Stanton, 2006).

All other industrialized countries spend significantly less on health care but have better health outcomes and a longer life expectancy. For example, the United States ranks among the worst of industrialized nations on important health indicators such as infant mortality, maternal mortality, and life expectancy at birth (Squires, 2014). Yet, in 2012, it ranked first in health care costs per capita at approximately $8915 per person (Organization for Economic Co-operation and Development [OECD], 2013b). This amounted to close to 18% of its GDP, compared with The Netherlands, which ranked second at 12% of its GDP (OECD, 2013a).

Cost-Containment Efforts

Over time, several approaches have been used to contain costs, including the following.

Regulation Versus Competition.

During the 1970s, modest government regulation attempted to contain health care costs through state rate-setting agencies and health planning mechanisms, such as Certificate of Need (CON) programs and regional Health Systems Agencies (HSAs), which evaluated and approved applications for the construction of new facilities, beds, and new technology. During the 1980s and early 1990s, when proponents of competition and free market health care became politically more influential, rate setting and CON programs were weakened and HSAs were eliminated. While free-market principles, as they apply to health care, have few similarities to a fully competitive market in economic terms, the rise of managed care programs and competition among health insurance plans in the 1980s may have temporarily slowed the growth of health costs before they began to rise again. As health insurers expanded the use of copayments, deductibles, and coinsurance as economic incentives to discourage care, the onus of cost-containment fell more heavily on the consumer/patient. However, ample research shows that low-income people may avoid necessary care because of copayments and deductibles. Chapter 17 more fully describes the mechanisms underlying the market system in health care.

Managed Care.

The origins of today’s managed care plans were in early prepaid health plans of the 1920s, which evolved into Health Maintenance Organizations (HMOs) in the 1970s, and into a variety of models in the subsequent 30 years, including Preferred Provider Organizations (PPOs). A managed care system shifts health care delivery and payment from open-ended access to providers, paid for through fee-for-service reimbursement, toward one in which the provider is a gatekeeper or manager of the patient’s health care and assumes some degree of financial responsibility for the care that is given through a capitated budget in which to pay for the patient’s care. Managed care implies not only that spending will be controlled but also that other aspects of care will be managed, such as quality and accessibility. In managed care, the primary care provider has traditionally been the gatekeeper, deciding what specialty services are appropriate and where these services can be obtained at the lowest cost. In the 1990s, negative media attention concerning the incentives to restrict care in the managed care model fueled a political backlash. Consumer and provider demands for 180greater choice for services and access to providers caused managed care plans to loosen gatekeeper requirements and provide more direct access to specialists. As a result, managed care became less effective in holding down expenditures and fueled a rise in health insurance premiums.

In addition, concerns of consumers and providers cha

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