1-28. Multiple choice. Choose the single most appropriate answer.
1-28. Multiple choice. Choose the single most appropriate answer.1. The stimulus that inspired managed care was (hint: inspired not facilitated):A. federal legislationB. soaring medical costsC. a decline in hospital admissionsD. President Clintons proposed health insurance plan2. Before managed care, most insurance plans were:A. paid for by the subscriberB. federally fundedC. provider-sponsored organizationsD. indemnity or fee-for-service3. Case management is:A. a synonym for managed careB. the precursor of managed careC. a synonym for HMOD. one method for achieving managed care4. The health plan that is responsible for both the financing and delivery of health services is:A. ASOB. TPAC. HMOD. PPM5. The health plan that allows subscribers choices by coordinating care through a network ofproviders is called:A. PPOB. POSC. HMOD. PHO6. In the staff model type of health maintenance organization:A. the physicians are HMO employeesB. the HMO contracts with a medical groupC. the HMO constructs a network of providersD. the employer contracts directly with individual physicians
7. A network of health care providers who agree to discounted rates is:A. a PPOB. an IPAC. a group model HMOD. a staff model HMO8. If Mary Jones requires a mastectomy for treatment of her breast cancer, and she has a staffmodel HMO plan, she will probably:A. choose a surgeon and hospital from the members directory of providersB. go to an HMO hospital and use an HMO-employed surgeonC. choose any surgeon and hospital she wants as long as she pays her deductible and co-paymentD. none of the above9. Susan Jones is a 33-year old computer programmer for a major airline. She was struck by aslow-moving automobile while jogging near her home. The paramedics transported her to thenearest hospital where she was diagnosed with fractures of her right tibia and fibula, plusnumerous lacerations and abrasions. She will need surgical repair of her leg. Her healthinsurance plan is a PPO and the hospital is not a member of the PPO network. Will this hospitalbe allowed to admit and treat Susan?A. No, because they are not a member of Susans preferred provider network.B. Yes, if the hospital calls for authorization from the PPO.C. Yes, if that is what Susan wants. She may get a better price for care if the hospital is part of her PPO network, but she will not be denied care when they are out-of-network.D. No, since it is not a life-threatening emergency.10. The health plan that bypasses the middleman (insurance carrier) is:A. PPOB. EPOC. HMOD. PSO11. Hospitals may be paid an all-inclusive amount for each case admitted, regardless of length ofstay. This reimbursement is based on:A. an indemnity benefitB. the DRGC. a per diem rateD. cost plus charges
12. Which of the following is NOT a function of managed care:A. shorten lengths of stayB. oversight of the medical care givenC. promote contractual relationships with providersD. implement rules tied to covered benefits13. Provider reimbursement based on prior costs, current market share or member population size is called:A. Fee for serviceB. CapitationC. Contact capitationD. Salary14. Physicians share in the financial risk of funding the medical services needed by a MCO member population in all of the following ways EXCEPT:A. WithholdsB. Shared risk fundsC. Claim ReservesD. Capitation15. All of the following are examples of "Fifth Generation Managed Care" EXCEPT:A. Anticipatory case managementB. Community based needs assessmentC. Targeted disease managementD. Use of clinical practice guidelines16. A market assessment of Denver, CO, noted strong managed care penetration, that HMO market share was at about 60%, and the existence of many multi-specialty provider groups. Furthermore, Columbia just completed implementation of the citys first fully integrated health system. Given this analysis, the best description for Denvers stage of growth is:A. UnstructuredB. Loose AlliancesC. ConsolidatedD. Competing Integrated Systems17. Managed care product development is heavily influenced by:A. Managed care penetrationB. Demographics of population where product is to be offeredC. Presence of employer and physician organizations in the communityD. All of the above
18. Examples of demand management include all of the following EXCEPT:A. Self-care guidesB. Ask-a-nurse servicesC. Pre-certification for high cost servicesD. Preventive care scheduling19. Barriers to increasing integration of information systems into the delivery of health services include all of the following EXCEPT:A. High costB. Lack of technology sophisticated enough to address health services issuesC. Lack of standardized systemsD. Issues of patient confidentiality20. Underwriting a managed care product involves:A. Assessment of provider reimbursement changesB. Determination of special benefits such as infertility and pharmacyC. Development of a target premium rateD. Risk adjustment of premium rates21. Medical economics provides evidence-based knowledge to help health plan administrators address a growing multitude of challenges such as:A. Physician reimbursement methodsB. Premium pricingC. Evaluation of health interventions and outcomesD. All of the above22. Knowing who paid for or supported a particular intervention and the associated economic analysis helps health care professionals identify sources of:A. QualityB. ProfitC. BiasD. Marketing23. All of the following are examples of specific economic input parameters in the evaluation of health care EXCEPT:A. ProductivityB. EfficacyC. Side EffectsD. Administrative costs
24. According to the concept of scarcity, there can never be enough resources to satisfy all human needs and wants. Therefore, if more resources are put into a particular health care service or product, what is given up?A. DemandB. Cost-effectivenessC. Opportunity costsD. Alternative inputs25. This medical economic analysis tool measures health care costs in terms of therapeutic objectives, such as a greater ability to produce reductions in blood pressure:A. Cost-Benefit AnalysisB. Cost-Minimization AnalysisC. Cost-of-Illness AnalysisD. Cost-Effectiveness Analysis26. Recent studies have documented that Zofrin, an antiemetic used in conjunction with chemotherapy regimens, helps to improve quality of life to levels twice as high as an alternative drug, Kytril. If a study were done elucidating information about the expected increase in life expectancy due to use of the two drugs, what measure could we use to determine which drug has the greatest utility?A. Benefit to cost ratioB. Cost-Effectiveness ratioC. Quality adjusted life years (QALYs)D. None of the above27. A component in the evolution of managed care is portrayed by what key difference in HEDIS 2.0 and HEDIS 3.0?A. The movement toward measuring the cost-effectiveness of new technologiesB. The movement toward use of measures to predict quality of careC. The movement toward measuring the impact of practice guidelinesD. The movement toward measuring the outcomes of specific chronic conditions28. Increasing market share serves what main purposes in the context of competition in managed care:A. Advancement of medical technology and the development of information systemsB. Decreasing unit costs by spreading fixed costs and increasing market powerC. Decreases overall administrative costs and promotes a positive imageD. None of the above
29. A physician who directs and coordinates the care of a member in a managed care plan is a :A. ProviderB. PurchaserC. Gate KeeperD. Case Manager30. Contracted physicians or groups of independent physicians is what type of HMO model:A. Network ModelB. IPA ModelC. Staff ModelD. Group Model31. Networks of hospitals, physicians, and other healthcare professionals that provide medicalcare to individuals for a negotiated fee are:A. PPOsB. HMOsC. POSD. PHO32. The type of HMO where the HMO does not provide members with financial coverage whenthey use non-panel providers or when they seek care directly from network specialists is:A. closed-panel HMOB. open-panel HMOC. EPOD. POS33. Which of the following has out-of-network coverage:A. EPOB. closed-panel HMOC. UROD. POS34. An example of a specialty carve-out would include all of the following EXCEPT:A. PsychotherapyB. Wisdom Tooth ExtractionC. Annual Physical ExamD. Eye Exam for glasses
35. The amount MCOs charge purchasers to provide health coverage for beneficiaries is knownas:A. Premium RateB. Going RateC. Fee-for-serviceD. Capitatiom36. Key components of a market assessment include all of the following EXCEPT:A. Competitive AnalysisB. Provider AssessmentC. Economic ProfileD. Product Development37. All of the following are characteristics of managed care EXCEPT:A. Restricted access to specialty providersB. Coverage for injury onlyC. Financial controls of careD. Prospective review of treatment38. All of the following are characteristics of traditional insurance EXCEPT:A. Financial controls of careB. Collections of claims data onlyC. Assumption of all financial riskD. Retrospective audit of claims39. A basic HMO model is:A. POSB. PMPCB. IPAC. EPO40. Requiring the member to obtain an authorization from the MCO or PCP before seeking thecare from specialists is known as:A. A referral authorizationB. pre-certificationC. case managementD. specialty carve-out
41. The process of rating can include all of the following EXCEPTA. A community ratingB. Self-fundingC. Experience ratingD. Claims history of the employerE. All of the above42. Which is not a function of managed care:A. Decrease length of stayB. Oversight of medical care givenC. Implement rules tied to covered benefitsD. Promote contractual relationships with providers43. Which law prohibits physicians from referring patients to a clinical laboratory in which theprovider has an ownership or investment interest:A. McCarren-FergusonB. StarkC. ShermanD. Clayton44. Passed by Congress to protect employee health benefit programs by giving fudiciaryresponsibilities to the employers who manage such programs and establishing penalties formismanagement of employee pension funds and other benefits isA. StarkB. ERISAC. McCarren-FergusonD. HMO Act of 197345. A market assessment of Denver, CO, noted strong managed care penetration, that HMOmarket share was at about 60%, and the existence of many multi-specialty provider groups.Furthermore, Columbia just completed implementation of the citys first fully integrated healthsystem. Given this analysis, the best description for Denvers stage of growth is:A. UnstructuredB. Loose AlliancesC. ConsolidatedD. Competing Integrated Systems
46. Recent studies have documented that Zofrin, an antiemetic used in conjunction withchemotherapy regimens, helps to improve quality of life to levels twice as high as an alternativedrug, Kytril. If a study were done elucidating information about the expected increase in lifeexpectancy due to use of the two drugs, what measure could we use to determine which drug hasthe greatest utility?A. Benefit to cost ratioB. Cost-Effectiveness ratioC. Quality adjusted life years (QALYs)D. None of the above47. If Stephen Downing needed an appendectomy for a ruptured appendicitis and he has a staffmodel HMO plan, he will have to:A. choose a surgeon and hospital from the members directory of providersB. choose a general surgeon who works for an HMO in an HMO hospitalC. choose any surgeon and hospital she wants as long as she pays her deductible and co-paymentD. choose an HMO-employed general surgeon in a hospital48. The key difference between HEDIS 2.0 and HEDIS 3.0 is?A. The trend toward measuring the cost-effectiveness of new technologiesB. The trend toward use of measures to predict quality of careC. The trend toward measuring the impact of practice guidelinesD. The trend toward measuring the outcomes of specific chronic conditions49.60. Write the most appropriate letter for each item in the space provided.A. vertically integrated ___ 49. HMO "gatekeeper"B. horizontal integration ___ 50. effect of FFSC. decreased utilization ___ 51. health system with one board of directorsD. increased utilization ___ 52. may depend on board certificationE. IPA ___ 53. separates plan funding & provider paymentF. PSO ___ 54. emerging provider owned organizationG. cause and without cause ___ 55. example: Broward County School BoardH. credentialing ___ 56. effect of capitationI. malpractice insurance requirements ___ 57. found in most contract termination clausesJ. population-based medicine ___ 58. a contracted provider dutyK. PCP ___ 59. merger to increase market powerL. Purchaser ___ 60. discourages unlimited resources for the few61-70: Fill-in-the-blank.61. Private purchasers of managed care products can increase market power by forming _________________.62. One way of increasing physician satisfaction with managed care is to allow them to have
greater _________________ in negotiations regarding reimbursement and work schedules.63. Some analysts argue that capitation encourages excessive _________________ by PCPs.64. In medical economics, the cost of a therapy or other intervention is known as a(n) _________________.65. Over 325,000 total joint replacements are expected to occur this year in the United States with an estimated annual medical expenditure per case of $26,000. This is an example of a Cost-_________________ Analysis.66. When congress passed the ___________________, one way it fostered the development of HMOs across the country was by requiring employers to offer federally-qualified HMOs.67. A type of health plan that is more restrictive than indemnity insurance, but less restrictive than an HMO is a _________________.68. The most common way for a health plan to track revenue and expenditures is by using the measure known as ________________.69. The managed care department responsible for education about plan procedures, policies, covered benefits and co-pays is _______________________.70. Medicaid programs are pursing managed care much more aggressively since they have obtained _________________________ from HCFA to enroll beneficiaries in HMOs.71.80. Write the most appropriate letter for each item in the space provided.71. standards for MCOs72. case rate reimbursements A. Managed Care73. Public Health Perspective entwined in B. Traditional Insurance its philosophy C. Capitation74. TriCare D. NCQA75. Health insurance for aged/disabled E. Medicare persons F. Adjudication76. fee-for service G. Military Health Program77. reviews services for MCOs or self- H. URO funded groups I. Medicaid78. processing of claims J. DRG79. health insurance for low-income K. Credentialing individuals L. Pre-certification80. retrospective audit of claims M. Staff Model
81-90: Fill-in-the-blank.81. ________ is a cash bonus or other financial reward paid to a provider in return for referring apatient to another provider or facility for treatment82. The federal law that grants to states the authority and responsibility for regulating thebusiness of insurance is know as ___________.83. Information that shows results of specific medical treatments or process is _________.84. __________ is the process of assessing the necessity, appropriateness, and efficiency ofhealth care either before or during, or after services are rendered.85. _______ is a standardized set of performance measures collected by MCOs and accredited by_________.86. Groups of employers who join together to purchase health insurance coverage in a systematicway is a __________.87. In a ___________, the provider organization receives a capitation rate for all professionaland institutional services for a defined membership.88. ________________ are agreements between MCOs and providers that shift all or someportion of the financial risk of managing the care of members to the providers.89. ______________ is the techniques and programs MCOs use to reduce member demandfor health care services and to encourage members to maintain good health.90. Most MCOs __________ network providers periodically to ensure that their qualificationsare still valid.