Hlth207 Ch.9
key implications to access
-determinant of health -benchmark in assessing effectiveness -equity -quality and efficient use of needed services
what two levels does payer driven competition occur at
-employers shop for the value in health insurance plans -- competition for insurers -managed care shops for best value from providers -- competition among providers
because of managed cares dominance in the US health care system, there is a 2 stage process in a managed care environment:
1. individuals select among health plans available to them (constrained by structural, financial, and personal characteristics) 2. individuals seek medical care, contained by both plan-specific and non plan factors
Among HMOs, which model is the most successful in terms of the share of all enrollments? Question 35 options: a) IPA model b) Network model c) Staff model d) Group model
A
Closely associated with concurrent UR is the function of Question 21 options: a) discharge planning b) rehabilitation c) preauthorization d) practice profiling
A
Prospective utilization review includes Question 19 options: a) precertification b) review of medical records c) efforts to reduce length of stay d) discharge planning
A
A hybrid between an HMO and a PPO. Question 38 options: a) IPA b) Point-of-service plans c) Mixed model HMO d) Exclusive provider plans
B
An experienced health care professional, such as a nurse practitioner, coordinates an individual's total health care. Question 15 options: a) closed-panel utilization b) case management c) gatekeeping d) utilization review
B
Monitoring of physician-specific practice patterns. Question 24 options: a) retrospective utilization review b) practice profiling c) concurrent utilization review d) case management
B
PPOs differentiated themselves by offering _____ option to enrollees. Question 37 options: a) discount b) open-panel c) point of service d) no out-of-pocket payment
B
What main disadvantage does an HMO have when using the IPA model? Question 32 options: a) It has difficulty recruiting physicians b) If a contract is lost, the HMO loses a large number of participating physicians c) It must take on additional administrative and utilization control responsibilities d) It is not favored by the enrollees
B
Which of the following is not used in pharmaceutical management? Question 18 options: a) Utilization review b) Disease management c) Drug formularies d) Tiered cost sharing
B
Who employs the physicians in the group practice model? Question 30 options: a) The HMO b) The group practice c) The IPA d) The PPO
B
Why was Medicare Part C created? a) To extend benefits to people with end-stage renal disease b) To channel beneficiaries into managed care programs c) To add a prescription drug benefit to the Medicare program d) To provide services to children up to the age of 19
B
Capitation is best described as Question 5 options: a) monthly lump sum payment regardless of utilization b) monthly lump sum payment regardless of cost c) fixed monthly fee per member d) payments capped to a maximum cost for delivering services
C
Concurrent UR in a hospital will be primarily concerned with the Question 20 options: a) disease process b) preauthorizations c) length of stay d) quality management
C
Cost-effective management of care for patients who have complex medical conditions. Question 16 options: a) Gatekeeping b) Utilization management c) Case management d) Managed care
C
Discounted fees are Question 8 options: a) used to shift risk from the financiers to the insurers b) used to share maximum risk with providers c) a modified form of fee for service d) discounted capitated fees
C
Fee for service promoted Question 11 options: a) price controls b) provider-induced demand c) both moral hazard and provider-induced demand d) moral hazard
C
Gatekeeping ______ secondary care services. Question 14 options: a) does not control b) encompasses the delivery of c) requires a referral for d) bypasses
C
Gatekeeping heavily depends on the services of a Question 13 options: a) case manager b) nurse practitioner c) primary care physician d) disease consultant
C
One goal of ______ in pharmaceutical management is to change physicians' future prescribing habits if necessary. Question 23 options: a) prospective utilization review b) concurrent utilization review c) retrospective utilization review d) case management
C
PPOs were created by ____ in response to HMOs' growing market share. Question 36 options: a) independent contractors b) hospitals c) insurance companies d) physicians
C
What is the purpose of risk sharing with providers? Question 4 options: a) It rewards providers for quality b) It makes providers immune to costs c) It makes providers cost conscious d) It keeps insurance premiums low
C
Which HMO model is likely to require heavy capital outlays to expand into new markets? Question 29 options: a) Network model b) IPA model c) Staff model d) Group model
C
Which type of MCO has achieved the greatest success in employment-based enrollment? Question 39 options: a) HMOs b) POS plans c) PPOs d) Exclusive provider plans
C
Closed-panel plan. Question 12 options: a) New enrollees are not accepted by the plan b) The enrollee cannot switch from one plan to another c) No new physicians can be added to the plan d) The enrollee is restricted to the providers on the panel
D
In the term, managed care, 'manage' refers to Question 9 options: a) management of premiums b) management of the supply of services c) management of risk d) management of utilization
D
In which HMO model is the choice of physicians likely to be most restricted? Question 28 options: a) IPA model b) Network model c) Group model d) Staff model
D
Physicians are employees of the HMO. Question 26 options: a) IPA model b) Preferred providers c) Independent practice association d) Staff model
D
Self insurance was spurred by a) self-employed people b) managed care organizations c) employers d) government policy
D
Under capitation, risk is shifted Question 6 options: a) from the provider to the MCO b) from the employer to the MCO c) from the insured to the employer d) from the MCO to the provider
D
Under the fee-for-service system, providers had the incentive to Question 10 options: a) indiscriminate cost increases because they could get paid whatever they would charge b) increase the level of quality in order to attract more patients c) use less technology because they could increase their revenues by not using costly procedures d) deliver more services than what would be medically necessary because a greater volume would increase their revenues
D
Under which payment method is a fee schedule used? Question 7 options: a) prospective payment b) capitation c) fee for service d) discounted fees
D
When an MCO adopts capitation as the primary method of payment, which service is likely to be carved out? Question 25 options: a) Specialty care b) Primary care c) Gatekeeping d) Mental health
D
Which HMO model is likely to provide the greatest control over the practice patterns of physicians? Question 27 options: a) Network model b) IPA model c) Group model d) Staff model
D
Which of the following is a major criticism of managed care? a) Managed care is inefficient b) Utilization may increase c) Managed care will worsen the physician oversupply d) Quality of care may be sacrifice
D
Who is likely to bear the most financial risk under the IPA model? Question 34 options: a) The providers b) The employers c) The HMO d) The IPA
D
The roles and responsibilities of health services administrators include:
Departments of management Program oversight Leadership and strategic direction
True or False? All MCOs are now required to be accredited by the National Committee for Quality Assurance.
F
True or False? By law, an HMO is prohibited from having an exclusive contract with a group practice.
F
True or False? Disease management is highly individualized.
F
True or False? In the 1990s, managed care was widely credited for enabling small employers to offer health insurance coverage to their employees.
F
True or False? Research shows that quality of care has declined as managed care has continued to grow.
F
True or False? The four main HMO models differ according to payment arrangements with physicians.
F
who is the utilization controls employed by
MCOs
True or False? A triple-option plan includes indemnity insurance as an option.
T
True or False? By prescribing minimum medical loss ratios in health plans, the ACA will limit the percentage of premium revenue a health plan can use for administration, marketing, and profits.
T
True or False? Case management is mainly recommended for patients who need secondary and tertiary care more often than primary care.
T
True or False? Diversification is not achieved through horizontal integration.
T
True or False? In the IPA model, the IPA rather than the HMO contracts with the physicians.
T
True or False? The emergence of PPOs was triggered by competition between HMOs and commercial insurance companies.
T
True or False? The majority of Medicaid beneficiaries and enrollees in Medicare Advantage plans receive health care services through HMOs
T
True or False? The objective of horizontal integration is to control the geographic distribution of a service.
T
True or False? Under a payment arrangement in which physicians are paid a fixed salary and performance-based bonuses, risk is shifted from the MCO to the physicians.
T
True or False? Utilization is better controlled under a closed-panel plan than under an open-panel plan.
T
true or False? Today, the majority of health insurance exists in the form of managed care plans.
T
How does risk adjustment affect payments to managed care plans? Question 41 options: a) Risk adjustment takes into account the enrollees' health status b) Risk adjustment provides an incentive for improving quality c) Risk adjustment reduces out-of-pocket costs for the enrollees d) Risk adjustment shifts risk from the payer to the MCO
a
The Newborns' and Mothers' Health Protection Act of 1996 prohibits a health plan to offer less than _____ of inpatient stay following a normal vaginal delivery. Question 43 options: a) 48 hours b) 24 hours c) 3 days d) 4 days
a
Under which model is an HMO relieved of the burden to establish contracts with providers and monitor utilization? Question 33 options: a) IPA model b) Staff model c) Group model d) Network model
a
What payment method is used in Primary Care Case Management to reimburse physicians? Question 40 options: a) Fee for service b) Capitation c) Discounted fees d) Salaries
a
Which of these organizations was specifically created to bring management expertise to physician group practices? Question 46 options: a) Management services organizations b) Provider-sponsored organizations c) Physician-hospital organizations d) Virtual organizations
a
supply-side regulation -- has what laws
antitrust laws
A managed care organization functions like Question 3 options: a) a financier b) an insurer c) a regulator d) a provider
b
An organization ceases to exist as a separate entity and is absorbed into the purchasing corporation. Question 47 options: a) Merger b) Acquisition c) Alliance d) Joint venture
b
Regional health systems are often Question 52 options: a) horizontally integrated b) vertically integrated c) formed into virtual organizations d) formed into alliances
b
Two organizations cease to exist, and a new corporation is formed. Question 48 options: a) Joint venture b) Merger c) Acquisition d) Alliance
b
What is the ultimate aim of a highly integrated organization? Question 45 options: a) Bring physicians and hospitals together to compete with managed care b) Deliver a seamless array of services c) Become a risk bearing entity d) Obtain government contracts to participate in Medicaid and Medicare Advantage
b
Which legislation was mainly responsible for the decline of Medicare enrollments in managed care after a rise in enrollments? Question 42 options: a) Deficit Reduction Act of 2005 b) Balanced Budget Act of 1997 c) Tax Equity and Fiscal Responsibility Act of 1982 d) Medicare Prescription Drug, Improvement, and Modernization Act of 2003
b
With the growth of managed care, the balance of power in the medical marketplace swung toward Question 2 options: a) the supply side b) more regulation c) providers d) the demand side
d
The Newborns' and Mothers' Health Protection Act of 1996 prohibits a health plan to offer less than _____ hours of inpatient stay following a Caesarean section. Question 44 options: a) 120 b) 48 c) 96 d) 72
c
The phenomenon called 'moral hazard' results directly from Question 3 options: a) the uninsured status of a segment of the U.S. population b) inadequate payment to providers c) health insurance coverage d) managed care enrollment
c
When patients have multiple health problems, this is called:
comorbidity
MCOs act on whose behalf by overcoming the information gap patients face
consumers
A new corporation created by two partnering organizations remains independent. Question 49 options: a) Merger b) Acquisition c) Alliance d) Joint venture
d
Antitrust legislation is intended to provide checks against Question 53 options: a) payments for patient referrals b) self-referral of patients c) fraud and abuse d) anticompetitive behavior
d
Managed care was initially welcomed by Question 1 options: a) workers b) private insurance c) the government d) employers
d
Sharing of existing resources without joint ownership of assets. Question 50 options: a) Acquisition b) Joint venture c) Merger d) Alliance
d
What type of integration is represented by a chain of nursing homes? Question 51 options: a) Diversification b) Network c) Vertical integration d) Horizontal integration
d
what are the competitive approaches to cost containment
demand side incentives -supply side regulation -payer driven price competition -utilization controls
"cost sharing" is popular for what competitive strategy
demand-side incentives
utilization controls -- good they have done?
helped cut through some of the unnecessary or inappropriate services provided to consumers
what do antirust laws do
prohibit business providers that stifle competitions among providers and ensures competitiveness and efficiency of economic markets
health care competition can be based on what
technology, quality, amenities, and access
Physicians and hospitals in the US began consolidating and integrating mainly in response to
the growth of managed care
overall picture for cost sharing
will get services more cautiously if they are paying more for them and to ration with their own health care
