Healthcare

Front 1

1. Prior to the 1970s, health maintenance organizations (HMOs) were known as:

Back 1

Prepaid group practices

Front 2

2. The original impetus of HMOs development came from

Back 2

Providers seeking patient revenues
Consumers seeking access to health care
Employers

Front 3

3. The integral components of managed care are:

Back 3

Wellness and prevention
Primary care orientation
Utilization management

Front 4

4. Managed care is best described as:

Back 4

A broad and constantly changing array of health plans employers, unions, and other purchasers of care that attempt to manage cost, quality, and access to that care.

Front 5

5. The Managed care backlash resulted in which of the following?

Back 5

A reduction in HMO membership
New federal and state laws and regulations

Front 6

True or false? PPOs differ from HMOs because they do not accept capitation risk and enrollees who are willing to pay higher cost sharing may access providers that are not in the contracted network.

Back 6

True

Front 7

2. True or false? Blue Cross began as a physician service bureau in the 1930s.

Back 7

False

Front 8

True or false? The Balance Budget Act (BBA) of 1997 resulted in a major increase in HMO enrollment

Back 8

False

Front 9

4. True or false? Health care cost inflation has remained consistent since 1995.

Back 9

False

Front 10

Briefly explain how the HMO Act of 1973 may have retarded HMO development in the few years after its enactment.

Back 10

The Act imposed requirements on HMOs but not on indemnity carriers or self-insured groups, thereby reducing the ability of HMOs to compete. In addition, because the government was slow to issue the Act's regulations, employers were reluctant to contract with HMOs until they knew the rules under which they would be operating.

Front 11

2. Briefly explain how the HMO Act of 1973 contributed to the growth of managed care.

Back 11

The HMO Act of 1973 authorized start-up funding and ensured access to employer-based insurance. The dual choice provision required any employer with more than 25 employees to offer at least one closed panel and one open panel HMO. In addition, federal qualification was perceived as an endorsement (a “seal of good housekeeping”) by the government in that the HMO met certain standards.

Front 12

True or false? HMOs are licensed as health insurance companies.

Back 12

False

Front 13

2. True or false? An IPA is an HMO that contracts directly with physicians and hospitals.

Back 13

False

Front 14

True or false? The defining feature of a direct contract model is the HMO contracting directly with a hospital to provide acute services to its members.

Back 14

False

Front 15

An IDS can be described as a legal entity consisting of more than one type of provider to manage a population’s health care and/or contract with a payer organization.

Back 15

True

Front 16

True or false? The GPWW requires the participation of a hospital and the formation of a group practice.

Back 16

False

Front 17

A PHO is usually a separate business entity requiring the participation of a hospital and at least some of the hospital’s admitting physicians.

Back 17

True

Front 18

True or false? Hospitals purchased physician practices and employed physicians in the 1990s, but will no longer do so.

Back 18

False

Front 19

8. True or false? PSOs, created by the BBA of 1997, proved to be very popular and successful.

Back 19

False

Front 20

1. Key common characteristics of PPOs include:

Back 20

Selected provider panels
Negotiated payment rates
Consumer choice
Utilization management

Front 21

2. EPOs share similarities with:

Back 21

PPOs
HMOs

Front 22

3. Commonly recognized HMOs include:

Back 22

IPAs
Network
Staff and group

Front 23

4. Capitation is usually defined as

Back 23

Prepayment for services on a fixed, per member per month basis

Front 24

5. In what model does an HMO contract with more than one group practice provide medical services to its members?

Back 24

Network Model

Front 25

6. Advantages of an IPA include:

Back 25

Broader physician choice for members
More convenient geographic access
Requires less start-up capital

Front 26

1. Who has final responsibility for all aspects of an independent HMO?

Back 26

Board of Directors

Front 27

2. Medical Directors typically have responsibility for:

Back 27

Utilization management
Benefits determinations for appeals
Quality management

Front 28

3. Which organization(s) need a Corporate Compliance Officer (CCO)?

Back 28

Health plans with a Medicare Advantage risk contract
Hospitals

Front 29

True or false? The Finance Director, not the Marketing Director, has responsibility for enrollment forecasting.

Back 29

False

Front 30

Briefly explain the role of committees in the area of medical management

Back 30

In the medical management area, committees serve to diffuse some elements of responsibility and allow important input from the field into procedure and policy or even into case-specific interpretation of existing policy. Examples of committees are: credentialing committee, medical advisory committee, utilization review committee, pharmacy committee, and peer review committee.

Front 31

2. Briefly explain the functions of the HMO’s Board of Directors.

Back 31

The function of the board is governance: overseeing and maintaining final
responsibility for the plan. Final approval authority of corporate bylaws rests with the board as does setting and approving policy. General oversight of the profitability or reserve status rests with the board, as does oversight and approval of significant fiscal events and quality management.

Front 32

1. When selecting a hospital during the network development phase, an HMO considers:

Back 32

Occupancy rate
Cost of services
Scope of services

Front 33

2. Ancillary services are broadly divided into the following categories:

Back 33

Diagnostic and therapeutic

Front 34

3. Basic elements of credentialing include:

Back 34

Hospital privileges
Malpractice history
Medical license
Board certification

Front 35

4. State and federal regulations consistently apply network access standards to:

Back 35

HMOs
POS plans

Front 36

Which of the following organizations may conduct primary verification of a physician’s credentials?

Back 36

An HMO
A PPO
A CVO

Front 37

True or false? The HIPDB is a national health care fraud and abuse data collection program for the reporting and disclosure of certain final adverse actions taken against health care providers, suppliers, or practitioners.

Back 37

True

Front 38

True or false? Considerations for successful network development include geographic accessibility and hospital-related needs.

Back 38

True

Front 39

True or false? Physicians avoid working for hospitals as much as possible.

Back 39

False

Front 40

True or false? Hospital consolidation has been blocked more often than not by the Department of Justice (DOJ) and/or the Federal Trade Commission (FTC).

Back 40

False

Front 41

True or false? Managed care plans perform onsite reviews of hospitals and ambulatory surgical centers.

Back 41

False

Front 42

True or false? In markets with high levels of managed care penetration, hospitals are usually paid using a sliding scale discount on charges method.

Back 42

False

Front 43

True or false? The same methodology used to pay a hospital for inpatient care is usually also use to pay for outpatient care.

Back 43

False

Front 44

True or false? Fee-for-service payment is the most common method used by HMOs to pay specialists.

Back 44

True

Front 45

True or false? Consolidation in the payer industry has resulted in most hospitals being unable to obtain adequate rate increases.

Back 45

False

Front 46

1. The following term refers to an all-inclusive rate paid by the HMO for both institutional and professional services

Back 46

Bundled payment

Front 47

2. Which of the following forms of hospital payment contain no elements of risk sharing by the hospital?

Back 47

Sliding scale FFS

Front 48

3. What are the basic ways to compensate open-panel PCPs?

Back 48

Capitation
Fee-for-service

Front 49

4. Capitation is a physician payment method preferred by many HMOs because it:

Back 49

Eliminates the FFS incentive to overutilize
Costs are predictable
Is less costly to administer than FFS

Front 50

5. How are outlier cases determined by a hospital?

Back 50

Through the chargemaster

Front 51

6. Payment to a facility for outpatient procedures may be increased on a case-by-case basis through which of the following?

Back 51

Carve-outs

Front 52

True or false? The use of utilization guidelines targets only managed care patients and does not have an impact on the care of non–managed care patients.

Back 52

False

Front 53

True or false? Nurse-on-call or medical advice programs are considered demand management strategies.

Back 53

True

Front 54

3. True or false? UM focuses on telling doctors and hospitals what to do.

Back 54

False

Front 55

4. True or false? Hospital utilization varies by geographical area.

Back 55

True

Front 56

5. True or false? It is possible for a specialist to also act as a primary care provider.

Back 56

True

Front 57

1. Utilization management seeks to reduce practice variation while promoting good outcomes and ___.

Back 57

Reducing access
Maintaining costs
Increasing patients
A. None of the Above

Front 58

2. The most common measurement of inpatient utilization is:

Back 58

Bed days per thousand enrollees

Front 59

3. Claims review is an example of

Back 59

Retrospective review

Front 60

True or false? Nonphysician practitioners deliver most of the care in disease management systems.

Back 60

True

Front 61

True or false? Most of the care in disease management systems is delivered in the inpatient setting since the acuity is much greater.

Back 61

False

Front 62

True or false? Fee-for-service physicians are financially rewarded for good disease management in most environments.

Back 62

False

Front 63

4. True or false? Electronic clinical support systems are important in disease management.

Back 63

True

Front 64

True or false? Costs of noncatastrophic, recurring outpatient care have risen significantly in the past few decades.

Back 64

True

Front 65

6. True or false? Outbound calls to physicians are an important aspect to most DM programs.

Back 65

False

Front 66

True or false? The typical practicing physician has a good understanding of what is happening with his or her patient between office visits.

Back 66

False

Front 67

1. The least appropriate site for disease management is:

Back 67

Inpatient setting

Front 68

2. Establishing a high level of evidence regarding disease management guidelines ensures:

Back 68

Validity

Front 69

3. Common sources of information that trigger DM include:

Back 69

Claims
Pharmacy data

Front 70

1. Describe the goal of disease management.

Back 70

To reduce the frequency and severity of episodes of chronic disease so that retreatment and readmission costs are minimized.

Front 71

True or false? More than 90% of members of employer-sponsored health plans have access to prescription drug coverage, and over 90% of all prescriptions in the U.S. are reimbursed by insured prescription drug benefit programs.

Back 71

True

Front 72

True or false? Managed prescription drug programs must be flexible and customize pharmacy benefit designs to accommodate diverse financial and benefit richness desires of their customers.

Back 72

True

Front 73

What statement is true regarding the trends of traditional, non-specialty drugs (mostly oral and topical drugs dispensed in community pharmacy) and specialty drugs (biotech, injectables, high-cost orals)?

Back 73

A. Many expensive and popular traditional drugs are losing patent protection, and generics are driving a declining cost trend. A growing number of the drugs in the pipeline for FDA approval are injectable products and the specialty drug trend, already at 20%, is expected to increase.

Front 74

2. Electronic prescribing offers which of the following potential outcomes?

Back 74

Reduction in prescribing and dispensing errors
Improvement in physician drug formulary prescribing conformance
Reduction in drug interactions and resulting serious adverse effects

Front 75

In January 2006, what large federal prescription drug program was implemented that offered pharmacy benefits to more than 40 million people at that time and is expected to increase by 30% throughout the next decade?

Back 75

Medicare Part D

Front 76

4. Two desirable outcomes of tiered prescription member copayments are:

Back 76

The use of less expensive generic drugs increases and members save money by paying lower Tier 1 generic copayments

Front 77

5. One potential negative consequence of drug formularies with high copayments is:

Back 77

High copayments may be a barrier to adherence

Front 78

What is the common benefit design trend in commercial (employer group sponsored) prescription drug benefits?

Back 78

Increasing copayment amounts, especially for Tier 2 preferred brand drugs and Tier 3 non-preferred brand drugs.
Increasing use of percent coinsurance, especially for Tier 3 and Tier 4 specialty tiers when available.
Increasing number of consumer-directed health plan designs with higher front-end deductibles.

Front 79

Select the one technique for controlling drug benefits costs that MOST health plans and PBMs DO NOT routinely use.

Back 79

Value-based insurance designs that assign “high-value” drugs to Tier 1 for ALL therapeutic categories.

Front 80

8. What technique is used by many pharmaceutical companies with health plans and PBMs to increase formulary access and utilization of specific products?

Back 80

Rebates for preferred formulary position
Health economic data, including a growing number of head-to-head clinical trials
Member copayment coupons to offset copayment

Front 81

1. What is a PBM and in what do they specialize?

Back 81

A Pharmacy Benefits Management company or a Pharmacy Benefit Manager specializes in providing comprehensive and cost-efficient pharmacy prescription drug benefit programs and component services that are customized to meet the clinical and financial needs employer groups, health plans, Medicaid programs, Medicare D plans, and other government programs.

Front 82

True or false? The majority of prescriptions for behavioral health medications are written by nonpsychiatrists.

Back 82

True

Front 83

True or false? Physicians treating gynecological patients diagnose substance abuse approximately 30% of the time.

Back 83

False

Front 84

3. True or false? Recent legislation encourages separate lifetime limits for behavioral care.

Back 84

False

Front 85

True or false? Extended inpatient treatment for substance abuse is clearly more effective, but too costly.

Back 85

False

Front 86

True or false? Behavioral health care providers are paid under methodologies similar to those applied to medical/surgical care providers.

Back 86

True

Front 87

True or false? Pay for performance (P4P) cannot be applied to behavioral health care providers.

Back 87

False

Front 88

1. Approximately 50% of behavioral care spending is associated with what percentage of patients?

Back 88

5%

Front 89

2. Which organization does not accredit managed behavioral health care companies?

Back 89

American College of Mental Health Administration

Front 90

True or false? HEDIS is the most widely used set of measures for reporting on managed behavioral health care.

Back 90

True