HLTH 210 Module 7

High-need, high cost patients comprise about 5 percent of the patient population, but drive roughly 50 percent of health care spending. True or False?

True

Nearly half of people with health insurance in the US receive their coverage through an employer. True or False?

True

Approximately 70 percent of health spending can be attributed to wasteful or excess costs, including costs associated with unnecessary services, inefficiently delivered services, excess administrative costs, prices that are too high, missed prevention opportunities, and fraud. True or False?

False

CPT is: A) A uniform language for coding services and procedures to streamline reporting and increase accuracy and efficiency. B) The set of services provided to treat a clinical condition or procedure C) A classification system that groups patients according to diagnosis, type of treatment, age, and other relevant criteria. Under the prospective payment system, hospitals are paid a set fee for treating patients in a single category, regardless of the actual cost of care for the individual. D) A national standard that represents the relative amount of physician work, resources, and expertise needed to provide services to patients; represents the actual dollar amount of payment to a physician on a fee-for-service basis after applying a conversion factor.

A) A uniform language for coding services and procedures to streamline reporting and increase accuracy and efficiency.

Which of the following is the best description of Category 2 in the framework HHS adopted to categorize health care payment models? A) At least a portion of payments vary based on the quality or efficiency of health care delivery B) Payment is not directly triggered by service delivery so volume is not linked to payment. Clinicians and organizations are paid and responsible for the care of a beneficiary for a long period (e.g., >1 yr) C) Some payment is linked to the effective management of a population or an episode of care. Payments still triggered by delivery of services, but opportunities for shared savings or 2-sided risk D) Payments are based on volume of services and not linked to quality or efficiency

A) At least a portion of payments vary based on the quality or efficiency of health care delivery

Bundled payments are: A) Models of care which link payments for the multiple services beneficiaries receive during an episode of care. B) A group of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to a population of patients they serve. C) A national standard that represents the amount of physician work, resources, and expertise needed to provide services to patients; represents the actual dollar amount of payment to a physician on a fee-for-service basis after applying a conversion factor. D) A fixed prepayment made to a group of providers or a health care system (as opposed to a health care plan), covering most or all of a patient's care during a specified time period. Global payments are usually paid monthly per patient over a year, unlike fee-for service, which pays separately for each service.

A) Models of care which link payments for the multiple services beneficiaries receive during an episode of care.

Which of the following is the best description of Category 4 in the framework HHS adopted to categorize health care payment models? A) Payment is not directly triggered by service delivery so volume is not linked to payment. Clinicians and organizations are paid and responsible for the care of a beneficiary for a long period (e.g., >1 yr) B) At least a portion of payments vary based on the quality or efficiency of health care delivery C) Some payment is linked to the effective management of a population or an episode of care. Payments still triggered by delivery of services, but opportunities for shared savings or 2-sided risk. D) Payment s are based on volume of services and not linked to quality or efficiency.

A) Payment is not directly triggered by service delivery so volume is not linked to payment. Clinicians and organizations are paid and responsible for the care of a beneficiary for a long period (e.g., >1 yr)

An accountable care organization (ACO) is: A) Models of care which link payments for the multiple services beneficiaries receive during an episode of acre. B) A specified amount of money paid to a health plan or doctor. This is used to cover the cost of a patient''s health care services for a certain length of time. C) A value-based payment approach that gives added incentive payments to provide high-quality and cost-efficient care. D) A group of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to a population of patients they serve.

D) A group of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to a population of patients they serve.

Which of the following, if any, is NOT among the CMMl's seven categories of innovation models? A) Accountable Care B) Primary Care Transformation C) New Payment, Service Delivery, and Accountability Models D) None of the other options are correct; they are all among CMMl's seven categories of innovation models.

D) None of the other options are correct; they are all among CMMl's seven categories of innovation models.

Fee-for-service payment with no link of payment to quality of care falls into which category of the framework HHS adopted to categorize health care payment models based on how providers receive payment A) Category 4 B) Category 1 C) Category 2 D) Category 3

B) Category 1

Which of the following, if any, is NOT among the "fundamental challenges" facing American healthcare discussed in the assigned excerpts from Chapter 1 of the National Academy of Medicine's 2017 Vital Directions report? A) Persistent Inequities in health B) Excessive Innovation and Integration C) None of the other options are correct; they are all fundamental challenges identified in the assigned excerpts D) Rapidly aging population

B) Excessive Innovation and Integration

Which of the following, if any, is NOT among the "realistic tools" to address challenges facing American healthcare. as discussed in the assigned excerpts from Chapter 1 of the National Academy of Medicine's 2017 Vital Directions report? A) Promise of "big data" to drive scientific progress B) None of the other options are correct; they are all realistic tools to address challenges discussed in the reading. C) Fully embracing the centrality of population and community health D) A new paradigm for health care delivery and finance

B) None of the other options are correct; they are all realistic tools to address challenges discussed in the reading.

DRG is: A) A healthcare delivery model in which providers, including hospitals and physicians, are paid based on patient outcomes. B) A managed care plan in which patients can use doctors, hospitals, and providers that belong to the network, but can use doctors, hospitals, and providers outside of the network for an additional cost. C) A classification system that groups patients according to diagnosis, type of treatment, age, and other relevant criteria. Under the prospective payment system, hospitals are paid a set fee for treating patients in a single category, regardless of the actual cost of care for the individual. D) A fixed prepayment made to a group of providers or a health care system (as opposed to a health care plan), covering most or all of a patient's care during a specified time period. Global payments are usually paid monthly per patient over a year, unlike fee-for-service, which pays separately for each service.

C) A classification system that groups patients according to diagnosis, type of treatment, age, and other relevant criteria. Under the prospective payment system, hospitals are paid a set fee for treating patients in a single category, regardless of the actual cost of care for the individual.

Value-based healthcare (VBH) is: A) A fixed prepayment made to a group of providers or a health care system (as opposed to a health care plan), covering most or all of a patient's care during a specified time period. Global payments are usually paid monthly per patient over a year, unlike fee-for service, which pays separately for each service B) Models of care which link payments for the multiple services beneficiaries receive during an episode of care. C) A healthcare delivery model in which providers, including hospitals and physicians, are paid based on patient health outcomes. D) A specified amount of money paid to a health plan or doctor. This is used to cover the cost of a patient's health care services for a certain length of time.

C) A healthcare delivery model in which providers, including hospitals and physicians, are paid based on patient health outcomes.

Fee-for-service is: A) The set of services provided to treat a clinical condition or procedure. B) A uniform language for coding medical services and procedures to streamline reporting and increase accuracy and efficiency. C) A method in which doctors and other health care providers are paid for each service performed. D) Models of care which link payments for the multiple services beneficiaries receive during an episode of care.

C) A method in which doctors and other health care providers are paid for each service performed.

RVU is: A) A method in which doctors and other health care providers are paid for each service performed. B) The set of services provided to treat a clinical condition or procedure. C) A national standard that represents the relative amount of physician work, resources, and expertise needed to provide services to patients; represent the actual dollar amount of payment to a physician on a fee-for-service basis after applying a conversion factor. D) A uniform language for coding medical services to streamline reporting and increase accuracy and efficiency.

C) A national standard that represents the relative amount of physician work, resources, and expertise needed to provide services to patients; represent the actual dollar amount of payment to a physician on a fee-for-service basis after applying a conversion factor.

Which of the following is Category 3 of HHS's framework for categorizing health care payment models based on how providers receive payment: A) Fee-for-service with no link of payment to quality B) Fee-for-service with a link to quality C) Alternative payment models built on fee-for-service architecture D) Population-based payment

C) Alternative payment models built on fee-for-service architecture

Which of the following, if any, is NOT among the seven principles guiding efforts by the U.S. Department of Health & Human Services (HHS) to transition to alternative payment models (APMs)? A) Value-based incentives should be intense enough to motivate providers to invest in and adopt new approaches to care delivery. B) Payment models that do not take quality into account are not considered APMs in the APM Framework, and do not count as progress toward payment reform. C) None of the other options are correct; they are all among the seven principles guiding efforts to transition to APMs D) Patients must be empowered as partners in health care transformation; changing providers' financial incentives is not sufficient to achieve person-centered care.

C) None of the other options are correct; they are all among the seven principles guiding efforts to transition to APMs

Which of the following, if any, is NOT among the findings from an evaluation by Avalare examining the Alternative Quality Contract (AQC) payment reform initiative by Blue Cross Blue Shield of Massachusetts (BCBSMA): A) Providers can implement meaningful change, but need time, consistent goals, and a similar commitment from payers to do so. B) Payers with significant local presence are best positioned to implement innovative payment models. C) None of the other options are correct; they are all true of the Avalare evaluation of BCBSMA's AQC program. D) New payment models should hold providers accountable for the full range of patient care costs.

C) None of the other options are correct; they are all true of the Avalare evaluation of BCBSMA's AQC program.

Which of the following, if any, is NOT among the findings from an evaluation by Avalare examining the Alternative Quality Contract (AQC) payment reform initiative by Blue Cross Blue Shield of Massachusetts (BCBSMA): A) None of the other options are correct; they are all true of the Avalare evaluation of BCBSMA's AQC program. B) Changing behavior requires providers to have "skin in the game," but payers need to meet providers where they are today C) Payment reform programs play a very insignificant role in changing provider behavior D) Providers need detailed spending and quality information and clinical support to take on risk

C) Payment reform programs play a very insignificant role in changing provider behavior

Which of the following, if any, is NOT among the seven principles guiding efforts by the U.S. Department of Health & Human Services (HHS) to transition to alternative payment models? A) None of the other options are correct; they are all among the seven principles guiding efforts to transition to APMs B) Health care spending must shift significantly toward population-based, more person-focused payments. C) Value-based incentives should ideally reach only healthcare administrators, but not the providers that deliver care, who should never consider financial factors in determining the appropriateness of care. D) Value-based incentives should be intense enough to motivate providers to invest in and adopt new approaches to care delivery.

C) Value-based incentives should ideally reach only healthcare administrators, but not the providers that deliver care, who should never consider financial factors in determining the appropriateness of care.

PPO is: A) The set of services provided to treat a clinical condition or procedure B) Models of care which link payments for multiple services beneficiaries receive during an episode of care. C) A method in which doctors and other health care providers are paid for each service performed. D) A managed care plan in which patients can use doctors, hospitals, and providers that belong to the network, but can used doctors, hospitals, and providers outside of the network for an additional cost.

D) A managed care plan in which patients can use doctors, hospitals, and providers that belong to the network, but can used doctors, hospitals, and providers outside of the network for an additional cost.

Capitation is: A) A value-based payment approach that gives added incentive payments to provide high-quality and cost-efficient care. B) A classification system that groups patients according to diagnosis, type of treatment, age, and other relevant criteria. Under the prospective payment system, hospitals are paid a set fee for treating patients in a single category, regardless of the actual cost of care for the individual. C) Models of care which link payments for the multiple services beneficiaries receive during an episode of care. D) A specified amount of money paid to a health plan or doctor. This is used to cover the cost of a patient's health care services for a certain length of time.

D) A specified amount of money paid to a health plan or doctor. This is used to cover the cost of a patient's health care services for a certain length of time.