Exam

Front 1

Reasons why employers should focus on the quality of health care

Back 1

1. Errors
2. Utilization
3. Purchases
4. Relationships
5. Liability

Hint 1

1. Errors - there are numerous errors in the delivery of health care services.
2. Utilization - there is substantial evidence of extensive overuse and underuse of various health care services.
3. Purchases - poor quality of care erodes the value of health care purchases.
4. Relationships - lack of attention to quality of care can have negative consequences in relationships with employees, providers and others in the community.
5. Liability - failure to exercise due diligence in evaluating quality of care may impact an employers liability for a bad outcome of care.

Front 2

Compents of quality care

Back 2

1. Appropriateness
2. Excellence
3. Satisfaction

Hint 2

1. Appropriateness - given the current state of the art of medicine
2. Excellence - in the execution of care
3. Patient satisfaction

Front 3

Considerations in assessing physician quality

Back 3

1. ETC
2. malpractice
3. specialty
4. NCQA
5. MCO
6. communication

Hint 3

1. ETC - assess the physician's experience, training, and professional certifications.
2. malpractice - review the physician's history of malpractice claims
3. specialty - for physicians performing specialty procedures, consider advanced training, experience with the procedure, complication and mortality rates, and success rates.
4. NCQA - the NCQA has developed some programs to recognize high-quality physicians
5. MCO - for physicians in managed care plans, review performance report cards provided by the MCO.
6. communication - schedule an office visit for evalutating the physician's communication skills.

Front 4

Considerations in assessing hospital quality

Back 4

1. accreditations
2. JCAHO
3. satisfaction
4. AHA
5. Government
6. healthgrades.com
7. specific
8. teaching

Hint 4

1. accreditations - the hospital should have the appropriate accreditations (from the state, CMS and JCAHO)
2. JCAHO - consider the results of JCAHO onsite surveys
3. satisfaction - review hospital satisfactions survey results
4. AHA - american hospital association information (on facilities, personnel and services)
5. Government - government data sources on hospital performance
6. healthgrades.com - review hospital quality ratings provided by healthgrades.com and the leag frog
7. specific - for specific procedures or conditions of interest, consider contacting the hospital directly regarding volume of admissions, complication and mortality rates, and success rates.
8. teaching - consider whether the hospital is a major teaching hospital (these have lower mortality rates for certain conditions)

Front 5

Considerations in assessing MCO quality

Back 5

1. visit
2. state
3. CQP
4. NCQA - ECAP DS UD
5. JCAHO

Hint 5

1. visit - consider performing a site visit
2. state - information may be available from the state dept of public health or the state dept of insurance
3. CQP - review MCO's credentialing criteria, quality assurance plan and preventive care programs
4. NCQA - ECAP DS UD - Accreditation by the NCQA - MCO will be categorized into one of the following: excellent, commendable, accredited, provisional, denied, suspended, under review, discretionary review
5. JCAHO - uses a similar approach to NCQA (with various categories)

Front 6

provider approaches for improving quality (referred to as supply management)

Back 6

1. employers
2. guidelines
3. database
4. feedback
5. CQI

Hint 6

1. employers - large employers can use quality care data to selectively contract with providers
2. guidelines - use care guidelines
3. database - use a hospital database to identify deficiencies in quality and monitor quality improvements
4. feedback - provide feedback on hospital and medical staff performance
5. CQI - promote continuous quality improvement plans

Front 7

consumer approaches for improving quality (referred to as demand management)

Back 7

1. preventive
2. shared
3. disseminate
4. internet
5. tele-nurse
6. tele-DM

Hint 7

1. preventive - provide preventive services
2. shared - use shared decision making programs to get the consumer involved
3. disseminate - disseminate information about provider quality
4. internet - encourage the use of reliable internet sources (ie US dept of health and human services)
5. tele-nurse - offer telephonic nurse counseling services
6. tele-DM - offer telephonic disease management programs

Front 8

primary sources of data for measuring health plan performance

Back 8

1. claims
2. records
3. patient
4. population

Hint 8

1. claims - claims and utilization data - the least costly sources of data and readily available electronically, but data quality depends on examiners and providers who may not have a financial incentive to record good data
2. records - medical records - an accurate source of data, but costly and only includes information on care provided by that provider
3. patient - patient reported data - can report on services from all providers, but responses can be influenced by the form of the survey, the question wording, and the responses available.
4. population - population exposure data - currently unreliable and incomplete

Front 9

factors that affect the credibility of health plan performance measurement reports

Back 9

1. data
2. population
3. sample (size and selection)
4. yr2yr

Hint 9

1. data - data quality
2. population - selction of the population - need to know how the data will be used and results will be interpreted
3. sample (size and selection) - sample size - should be based on the smallest grouping at which results are to be interpreted. formula for calculating the needed sample = n = (Z*sigma/p)^2. sample selection should be random or stratified. the sample is used to make inferences about the population.
4. yr2yr - year to year consistency of health plan results - high turnover in providers and members reduces the predictability of future results

Front 10

categories for health plan performance evaluation

Back 10

1. access
2. financial
3. satisfaction
4. effectiveness

Hint 10

1. access - measured as the actual treatment received, the opportunity to receive health care treatment (patient w/in X miles of provider), or the ratio of providers to members
2. financials - cost and financial meausres - annual cost per member, regional vs. national costs. dependent on demographics, health plan benefits, reimbursement methods, and reserves.
3. satisfaction - can use a standardized survey, enrollment/disenrollment rates, grievances, or voluntary out of network coverage.
4. effectiveness - medical effectiveness - multiple measures are needed (Separate list)

Front 11

common measures of medical effectiveness

Back 11

1. preventive
2. guidelines
3. proxy
4. cost & utilization
5. outcomes

Hint 11

1. preventive - preventive care measures - does the doctor follow standards for immunizations, memmorgrams, etc.?
2. guidelines - practice guidelines - to measure if the doctor's care is conservative and efficient based on published guidelines
3. proxy - proxy indicators - events that correlate with poor treatment (i.e. rate of low birth weight babies or heart attack rates for males over 40)
4. cost & utilization - such as admission rates and average length of stay (measures approrpriate use of resources)
5. outcomes - health status outcome measures - assessed by clinicians, patients, or mortality/morbidity rates

Front 12

definition and uses of health indicators

Back 12

1. changes
2. level
3. safety
4. inform

Hint 12

*health indicators = standardized summary measures that represent health status.
1. changes - monitor changes over time and variations across health regions
2. level - identify levels of health and well being of a population
3. safety - help address patient safety issues by encouraging those with poor scores to improve
4. inform - provide evidence to inform health programs, policies, and funding decisions

Front 13

definition and uses of comparative effectiveness research

Back 13

1. persuade
2. disputes
3. errors
4. consistency

Hint 13

*comparative effectiveness research = aa rigorous evaluation of the impact of different options available to treat a specific condition
1. persuade - persuade providers to move from one therapy to another
2. disputes - clarify disputes over practice and policy
3. errors - help in the physician/patient interaction to reduce errors
4. consistency - help make decisions more consistent

Front 14

uses of quality and efficiency measurements

Back 14

1. quality
2. government
3. reporting
4. network
5. p4p
6. purchaser
7. prof standards & accreditation
8. education

Hint 14

1. quality - quality improvement
2. government - government oversight
3. reporting - public reporting
4. network - network development
5. p4p - pay for performance programs
6. purchaser - purchaser decision making
7. prof standards & accreditation - professional standards and professional accreditiaiton
8. education - consumer health education

Front 15

institute of medicine definition of quality

Back 15

SEE PET

Hint 15

1. safe - avoiding injuries to patients
2. effective - providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit
3. efficient - avoiding waste of equipment, supplies ideas and energy
4. patient centered - providing care that is respectful of and responsive to an individual patients preferences, needs and values
5. equitable - providing care that does not vary in quality because of personal characteristics
6. timely - reducing waits and sometimes harmful delays

Front 16

types of agents

Back 16

1. general
2. sub
3. brokerage

Hint 16

1. general - general agents - typically appointed by an insurer to be responsible for all business in a geographical area
2. sub - sub agents - hired by general agents to be the actual business producers
3. brokerage - a group of agents who are not affiliated with any particular insurer

Front 17

types of agent compensation

Back 17

1. commision, % and flat
2. service
3. override

Hint 17

1. commision, % and flat - percent of premium - rates vary by product, duration, persistency of the agent's buisiness, and the volume of business placed. flat commission per policy or per member - a movement toward this for inflation sensitive products.
2. service - service fees - sometimes paid to agents to compensate for services provided through the renewal process
3. override - commission override - this is an additional commission that is typically smaller than the commission itself, and is sometimes paid to general agents and brokerages.

Front 18

buyers of group insurance products and services

Back 18

1. ERs - single & trust
2. gov. - EE & social
3. unions
4. discretionary
5. associations
6. creditors

Hint 18

1. ERs - single & trust; single ERs - coverage may be purchased from an insurer, or the ER may self insure. multiple ER trusts - 2+ ERs join together to form a trust for the purpose of buying and funding group insurance.
2. gov. - EE & social; gov. EE group (FEHBA) and gov. social insurance programs (medicaid/care, social sec.)
3. unions - labor unions - labor union may be the policy holder or may negotiate on behalf of participating ERs
4. discretionary - discretionary groups - groups established primarily for the purpose of providing insurance or self-insured benefits (ie purchasing alliances)
5. associations - groups of individuals or institutions that share common professions, goals, interests or activities
6. creditors - creditor groups may purchase life or disability insurance on their debtors

Front 19

sellers of group insurance products

Back 19

1. insurance
2. HMOs
3. provider
4. serivce
5. self

"5 sell, 8 buy"

Hint 19

1. insurance - insurance companies
2. HMOs - health maintenance organizations - these are licensed as separate entities, even though they are commonly owned by insurance companies, blue plans, and provider groups.
3. provider - provider owned organizations - consist of provider groups who accept a scheduled global capitation payment for providing specific services
4. serivce - health care service corporations - not for profit entities, such as blue plans and delta dental plans.
5. self - self insured employers - often contract out the administrative aspects of the plan

Front 20

components of the managed care delivery system

Back 20

1. services
2. mix
3. network (capabilities and access)
4. managed (care and utilization)
5. quality
6. preventive
7. added
8. integrated

Hint 20

1. services - consumer services
2. mix - product mix - full spectrum of plans along the managed care continuum
3. network (capabilities and access) - provider networks (access to physicians, hospitals, and specialists of consistent quality) and network capabilites
4. managed (care and utilization) - care management (for chronic diseases) and utilization management (reduces unnecessary services while maintaining high quality care)
5. quality - credentialing, utilization, and outcomes data for specific providers
6. preventive - preventative programs - disease prevention and wellness
7. added - value added products and services - such as 24 hour access to medical and wellness information
8. integrated - auxiliary services, mental and dental health, home care, etc.

Front 21

challenges facing MCOs

Back 21

1. competition
2. consolidation
3. costs
4. quality
5. regulatory
6. sales
7. quality

Hint 21

1. competition - meeting choice based competition - consumers frequently have a choice between 2+ MCOs
2. consolidation - consolidation into larger entities - to increase coverage areas and achieve economies of scale
3. costs - increasing medical costs
4. quality - achieving quality - plan quality (through NCQA accreditation) and provider quality (through credentialing, profiling)
5. regulatory - regulatory pressure - for increased consumer rights
6. sales - achieving strategic sales goals - is challenging because the marketplace is now more informed and competitive
7. internet - effectively using the internet - meeting HIPAA mandates and meeting demands of the EEs, EERs and providers

Front 22

key decision makers in the managed care distribution process

Back 22

1. distribution
2. EEs
3. ERs
4. providers

Hint 22

1. distribution - distribution channels (brokers, consultants, direct sales to large ERs, financial institutions)
2. EEs - separate list for their criteria
3. ERs - separate list for their criteria
4. providers

Front 23

MCO selection criteria for ERs

Back 23

1. cost
2. quality
3. choice
4. service
5. network
6. HR
7. partner

Hint 23

1. cost - cost and financial suitability
2. quality - assurance of quality care
3. choice - choice of plan design
4. service - quality of local service
5. network - network access
6. HR - compatibility with HR's objectives
7. partner - a strong partner in health coverage

Front 24

MCO selection criteria for EEs

Back 24

1. cost
2. paperwork
3. choice
4. easy access
5. resource

Hint 24

1. cost - low out of pocket cost
2. paperwork - little and easy paperwork
3. choice - choice of plans
4. easy access - easy access to quality care, services and information
5. resource - having a physician that is a resource

Front 25

the sales process for MCOs

Back 25

1. opportunities
2. contact
3. needs
4. UW
5. prepare
6. present
7. close
8. consumer

Hint 25

1. opportunities - target opportunities - identify potential new clients
2. contact - contact prospects - communicate the MCO's desire to establish a relationship
3. needs - identify the needs of the potential client
4. UW - underwrite the risk
5. prepare - prepare the proposal - try to leverage the MCO's competitive advantages
6. present - present the solution
7. close - close the account
8. consumer - consumer sale - the final sale is to the EE

Front 26

types of advertising media

Back 26

1. TV
2. radio
3. print
4. outdoor
5. mail

Hint 26

1. TV - can be effective when seeking to increase market share and establish the MCO's brand
2. radio - effective in select periods (like open enrollment), can reach a certain demographic, and is cost effective
3. print - publications - essential for consumer pre-enrollment and post-enrollment (less costly than TV)
4. outdoor - billboards - can target audiences based on location and is cost effective
5. mail - direct mail - address specific issues in a personal and creative way

Front 27

selection criteria for choosing the type of advertising media

Back 27

1. goals
2. audience
3. budget
4. available
5. message
6. geographical

Hint 27

1. goals - what is the goal? brand awareness or specific information?
2. audience - what is the target audience (EEs, ERs, providers) and which vehicle will best reach that audience?
3. budget - what is the available budget?
4. available - what vehicles are available?
5. message - which vehicle will best support the message?
6. geographical - which vehicles are strongest in the geographical area?

Front 28

recent trends in the managed care market affecting ERs

Back 28

1. restructuring
2. competition
3. consumerism
4. cost
5. quality
6. emerging

Hint 28

1. restructuring - physician formed specialty groups and direct contracting by ERs
2. competition - causes focus to be on quick fixes rather than long term solutions
3. consumerism - EEs are more informed about health care and want more control over product and delivery
4. cost - cost increases - caused by cost shifting, aging population, providers resisting discounts, and increased utilization
5. quality - movement toward defining and measuring it
6. emerging - emerging trends likely to affect ERs in the future = aging population, internet, reduction in health plan capital

Front 29

advantages and disadvantages of managed care interventions

Back 29

A = efficiency, integration
D = anti, micro management, avoidance, variation, ratios

Hint 29

A = efficiency, integration
--efficiency - greater efficiency in use of resources (less IP, more OP)
--integration - better integration of prevention and treatment
D = anti, micro management, avoidance, variation, ratios
--anti-managed care sentiment
--excessive micro management of providers
--reduced provider to member ratios
--wide variation in practice patterns
--avoidance of sick patients and denial of care

Front 30

future trends in managed care

Back 30

1. technology
2. consumerism
3. competition
4. uniformity
5. legislation

Hint 30

1. technology - increases access to information and allows electronic transactions
2. consumerism - being driven by technology, aging population, and increased EE cost sharing
3. competition - will increase
4. uniformity - uniformity in medical practice - potential to become more systemized and evidence based
5. legislation - legislative changes - will affect health insurance market as a whole

Front 31

information needed in order to pay claims

Back 31

1. identity
2. proof
3. date
4. amount
5. beneficiary
6. COB.

Hint 31

1. identity - identity of policyholder and claimant to determine eligibility
2. proof - proof of loss/claim - according to the contract definition of loss
3. date - dat of loss - to determine that the claim occurred during the contract period
4. amount - amount of loss - according to the contract
5. beneficiary - beneficiary or assignee
6. COB - information regarding other coverage - for COB

Front 32

uses of claim information

Back 32

1. pricing
2. reserving
3. reporting
4. adjudication
5. monitoring
6. fraud

Hint 32

1. pricing
2. reserving
3. reporting - financial reporting
4. adjudication - claim adjudication
5. monitoring - provider monitoring
6. fraud - fraud and abuse control

Front 33

claim process for disability income

Back 33

1. initial
2. status
3. plan
4. benefits
5. ongoing

Hint 33

1. initial - initial determination of the potential liability (assess the claimants condition relative to the contractual definition of disability)
2. status - establish the disability status of the claimant - may involve an assessment by the claimant's physician, independent medical examination, or field investigations (surveillance)
3. plan - the insurer establishes a plan for managing the disability (timeline for recovery and rehabilitation)
4. benefits - determine the level periodic benefit payment - based on pre disability salary and offsetrs
5. ongoing - ongoing review of the disability to assure that payments are only made if claimants remains disabiled and to managed long term disabilities (consider lump sum payment or retraining)

Front 34

claim process for health insurance

Back 34

1. proof and eligibilty
2. eligible
3. gross
4. net

Hint 34

1. proof and eligibilty - benefit eligibility (consider the coverage limits, pre exisiting conditions, which expenses are eligible) and proof of loss (need bills with dates and illnesses to verify the loss)
2. eligible - determine eligible charges - usually the billed charges subject to usual and customary limits or a managed care schedule
3. gross - determine the gross benefit level - apply the ded., coins., OOP limit, and maximums (i.e. cost sharing)
4. net - determine the net payment - consider COB, subrogation and assignment of benefits

Front 35

componenets of the claim processing workflow

Back 35

1. receipt
2. OCR
3. repair
4. auto
5. payment

Hint 35

1. receipt - receipt processing - once it is received, the claim is logged into the system and given a unique identifier
2. OCR - paper claims are scanned and translated to electronic data using optical character recognition technology
3. repair - claims that do not contain all the necessary information are rejected and require manual intervention
4. auto - auto adjudication - if all the necessary fields are present, the system will adjudicate the claim automatically
5. payment - the payment process - some plans transmit funds electronically, while other send paper checks

Front 36

tools used for validating that a claimant is disabled

Back 36

1. exam
2. surveillance
3. phone

Hint 36

1. exam - examination by company physicians - the insurer my require that a physician of its choice examine the claimant, to validate the findings of the claimant's physician
2. surveillance - field examinations - a field investigator tries to discover if the claimant is performing tasks that he is supposedly unable to perform
3. phone - telephone validations - call the claimant and discuss the claim

Front 37

actions the insurer may take after evaluating a claim

Back 37

1. accept
2. reject
3. more
4. rescind

Hint 37

1. accept - claim is approved and payment is made
2. reject - claim is disapproved - the company will generally provide a reason for denial and the claimant will then have a chance to appeal
3. more - claim examiner requires more information in order to make a determination
4. rescind - contract is rescinded because of misrepresentation - this occurs when the insurer discovers intential misinformation on the application and when policy provisions allow for rescission

Front 38

types of medical management programs and activities

Back 38

1. utilization
2. quality
3. disputes

Hint 38

1. utilization - referral management programs, case management, pre admission/concurrent/retrospective review, utilization reporting and evaluation programs, provider incentive arrangement
2. quality - peer review, quality assurance and assessment programs, medical protocols and practice guidelines, provider selection and credentialing
3. disputes - such as member and provider grievance program