Deck 9: Managed Care and Integrated Organizations

Question 1

Under capitation, risk is shifted

A)from the insured to the employer
B)from the provider to the MCO
C)from the employer to the MCO
D)from the MCO to the provider

Answer 1

from the MCO to the provider

Question 2

Managed care was initially welcomed by

A)employers
B)workers
C)private insurance
D)the government

Answer 2

employers

Question 3

Capitation is best described as

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

Answer 3

fixed monthly fee per member

Question 4

Under the fee-for-service system, providers had the incentive to

A)deliver more services than what would be medically necessary because a greater volume would increase their revenues
B)use less technology because they could increase their revenues by not using costly procedures
C)indiscriminate cost increases because they could get paid whatever they would charge
D)increase the level of quality in order to attract more patients

Question 5

Self-care with professional support.

A)Preauthorization
B)Prospective utilization review
C)Disease management
D)Closed-panel utilization

Question 6

Fee for service promoted

A)price controls
B)moral hazard
C)provider-induced demand
D)both moral hazard and provider-induced demand

Question 7

With the growth of managed care, the balance of power in the medical marketplace swung toward

A)providers
B)the supply side
C)the demand side
D)more regulation

Question 8

A managed care organization functions like

A)a provider
B)an insurer
C)a regulator
D)a financier

Question 9

Under which payment method is a fee schedule used?

A)prospective payment
B)capitation
C)discounted fees
D)fee for service

Question 10

Discounted fees are

A)discounted capitated fees
B)used to shift risk from the financiers to the insurers
C)used to share maximum risk with providers
D)a modified form of fee for service

Question 11

An experienced health care professional, such as a nurse practitioner, coordinates an individual's total health care.

A)case management
B)utilization review
C)gatekeeping
D)closed-panel utilization

Question 12

In the term, managed care, 'manage' refers to

A)management of utilization
B)management of premiums
C)management of risk
D)management of the supply of services

Question 13

Which of the following is not used in pharmaceutical management?

A)Drug formularies
B)Disease management
C)Tiered cost sharing
D)Utilization review

Question 14

Closed-panel plan.

A)No new physicians can be added to the plan
B)New enrollees are not accepted by the plan
C)The enrollee cannot switch from one plan to another
D)The enrollee is restricted to the providers on the panel

Question 15

Prospective utilization review includes

A)precertification
B)discharge planning
C)review of medical records
D)efforts to reduce length of stay

Question 16

Gatekeeping ______ secondary care services.

A)bypasses
B)encompasses the delivery of
C)requires a referral for
D)does not control

Question 17

What is the purpose of risk sharing with providers?

A)It makes providers immune to costs
B)It makes providers cost conscious
C)It rewards providers for quality
D)It keeps insurance premiums low

Question 18

Concurrent UR in a hospital will be primarily concerned with the

A)disease process
B)length of stay
C)preauthorizations
D)quality management

Question 19

Gatekeeping heavily depends on the services of a

A)primary care physician
B)case manager
C)disease consultant
D)nurse practitioner

Question 20

Cost-effective management of care for patients who have complex medical conditions.

A)Case management
B)Gatekeeping
C)Utilization management
D)Managed care

Question 21

A network model HMO

A)employs its own network of physicians
B)exclusively uses the services of an independent practice association
C)owns a network of physicians and hospitals
D)contracts with more than one group practices

Question 22

Review of overutilization or underutilization is undertaken as part of

A)concurrent utilization review
B)retrospective utilization review
C)prospective utilization review
D)case management

Question 23

What main disadvantage does an HMO have when using the IPA model?

A)It has difficulty recruiting physicians
B)It must take on additional administrative and utilization control responsibilities
C)It is not favored by the enrollees
D)If a contract is lost, the HMO loses a large number of participating physicians

Question 24

Physicians are employees of the HMO.

A)Preferred providers
B)IPA model
C)Staff model
D)Independent practice association

Question 25

Monitoring of physician-specific practice patterns.

A)concurrent utilization review
B)retrospective utilization review
C)case management
D)practice profiling

Question 26

PPOs were created by ____ in response to HMOs' growing market share.

A)physicians
B)insurance companies
C)hospitals
D)independent contractors

Question 27

Which type of MCO has achieved the greatest success in employment-based enrollment?

A)HMOs
B)PPOs
C)POS plans
D)Exclusive provider plans

Question 28

When an MCO adopts capitation as the primary method of payment, which service is likely to be carved out?

A)Specialty care
B)Gatekeeping
C)Mental health
D)Primary care

Question 29

Which HMO model is likely to provide the greatest control over the practice patterns of physicians?

A)Staff model
B)Group model
C)Network model
D)IPA model

Question 30

PPOs differentiated themselves by offering _____ option to enrollees.

A)point of service
B)no out-of-pocket payment
C)open-panel
D)discount

Question 31

Which HMO model is likely to require heavy capital outlays to expand into new markets?

A)Staff model
B)Group model
C)Network model
D)IPA model

Question 32

Closely associated with concurrent UR is the function of

A)preauthorization
B)rehabilitation
C)practice profiling
D)discharge planning

Question 33

Among HMOs, which model is the most successful in terms of the share of all enrollments?

A)Staff model
B)Group model
C)Network model
D)IPA model

Question 34

Who is likely to bear the most financial risk under the IPA model?

A)The IPA
B)The providers
C)The HMO
D)The employers

Question 35

One goal of ______ in pharmaceutical management is to change physicians' future prescribing habits if necessary.

A)concurrent utilization review
B)retrospective utilization review
C)prospective utilization review
D)case management

Question 36

In which HMO model is the choice of physicians likely to be most restricted?

A)Staff model
B)Group model
C)Network model
D)IPA model

Question 37

Who employs the physicians in the group practice model?

A)The HMO
B)The group practice
C)The IPA
D)The PPO

Question 38

A hybrid between an HMO and a PPO.

A)Point-of-service plans
B)Mixed model HMO
C)IPA
D)Exclusive provider plans

Question 39

What payment method is used in Primary Care Case Management to reimburse physicians?

A)Capitation
B)Discounted fees
C)Fee for service
D)Salaries

Question 40

Under which model is an HMO relieved of the burden to establish contracts with providers and monitor utilization?

A)Staff model
B)Group model
C)Network model
D)IPA model

Question 41

How does risk adjustment affect payments to managed care plans?

A)Risk adjustment shifts risk from the payer to the MCO
B)Risk adjustment takes into account the enrollees' health status
C)Risk adjustment provides an incentive for improving quality
D)Risk adjustment reduces out-of-pocket costs for the enrollees

Question 42

Regional health systems are often

A)horizontally integrated
B)vertically integrated
C)formed into virtual organizations
D)formed into alliances

Question 43

A new corporation created by two partnering organizations remains independent.

A)Acquisition
B)Merger
C)Joint venture
D)Alliance

Question 44

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.

A)24 hours
B)48 hours
C)3 days
D)4 days

Question 45

Two organizations cease to exist, and a new corporation is formed.

A)Acquisition
B)Merger
C)Joint venture
D)Alliance

Question 46

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.

Question 47

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.

A)48
B)72
C)96
D)120

Question 48

Utilization is better controlled under a closed-panel plan than under an open-panel plan.

Question 49

What type of integration is represented by a chain of nursing homes?

A)Vertical integration
B)Network
C)Horizontal integration
D)Diversification

Question 50

What is the ultimate aim of a highly integrated organization?

A)Deliver a seamless array of services
B)Bring physicians and hospitals together to compete with managed care
C)Become a risk bearing entity
D)Obtain government contracts to participate in Medicaid and Medicare Advantage

Question 51

Case management is mainly recommended for patients who need secondary and tertiary care more often than primary care.

Question 52

Antitrust legislation is intended to provide checks against

A)anticompetitive behavior
B)fraud and abuse
C)self-referral of patients
D)payments for patient referrals

Question 53

Sharing of existing resources without joint ownership of assets.

A)Acquisition
B)Merger
C)Joint venture
D)Alliance

Question 54

All MCOs are now required to be accredited by the National Committee for Quality Assurance.

Question 55

The emergence of PPOs was triggered by competition between HMOs and commercial insurance companies.

Question 56

Disease management is highly individualized.

Question 57

Which legislation was mainly responsible for the decline of Medicare enrollments in managed care after a rise in enrollments?

A)Tax Equity and Fiscal Responsibility Act of 1982
B)Balanced Budget Act of 1997
C)Medicare Prescription Drug, Improvement, and Modernization Act of 2003
D)Deficit Reduction Act of 2005

Question 58

An organization ceases to exist as a separate entity and is absorbed into the purchasing corporation.

A)Acquisition
B)Merger
C)Joint venture
D)Alliance

Question 59

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.

Question 60

Which of these organizations was specifically created to bring management expertise to physician group practices?

A)Virtual organizations
B)Physician-hospital organizations
C)Provider-sponsored organizations
D)Management services organizations

Question 61

In the 1990s, managed care was widely credited for enabling small employers to offer health insurance coverage to their employees.

Question 62

By law, an HMO is prohibited from having an exclusive contract with a group practice.

Question 63

In the IPA model, the IPA rather than the HMO contracts with the physicians.

Question 64

The four main HMO models differ according to payment arrangements with physicians.

Question 65

The majority of Medicaid beneficiaries and enrollees in Medicare Advantage plans receive health care services through HMOs.

Question 66

Research shows that quality of care has declined as managed care has continued to grow.

Question 67

One distinguishing feature of HMOs is that they use discounted fees as the primary method of paying providers.

Question 68

Diversification is not achieved through horizontal integration.

Question 69

A triple-option plan includes indemnity insurance as an option.

Question 70

The objective of horizontal integration is to control the geographic distribution of a service.