TAMU PHLT 313 EXAM 3 UPDATED ACTUAL QUESTIONS AND CORRECT ANSWERS

TAMU PHLT 313 EXAM 3 UPDATED ACTUAL QUESTIONS
AND CORRECT ANSWERS

Question:
1. What is managed care?
Answer:
mechanism of providing health care services where a single organization takes on the management of:
- financing
-insurance
-delivery
- payment

Question:
2. The most common methods used for reimbursing providers are:
Answer:
- Capitation
- Discounted fees
- Salaries

Question:
3. Capitation
Answer:
The provider is paid a fixed monthly sum per enrollee, often called a "per member, per month (PMPM)
payment"

Question:
4. Discounted fees
Answer:
- A modified form of fee-for-service
- Discounts are offered in exchange for a certain volume of business

Question:
5. Salaries
Answer:
Generally combined with bonuses for efficiency

Question:
6. Accreditations set standards to measure performance
Answer:
- National Committee for Quality Assurance
- The Centers for Medicare and Medicaid Services (rates Medicare Part C plans)

Question:
7. Early 1900s

,Answer:
- railroad, mining, and lumber companies employed salaried physicians to provide care

Question:
8. 1929
Answer:
First private health insurance plan: Baylor University Hospital

Question:
9. 1940s
Answer:
Large health plans emerged in the US

Question:
10. 1973
Answer:
The Health Maintenance Organization Act

Question:
11. 1980s
Answer:
- Slow growth, but health care costs continued to rise
- Creation of other forms of managed care plasn

Question:
12. Medicare
Answer:
- Medicare Advantage gives beneficiaries the managed care choice
- Beneficiaries have the option to remain in fee-for-service
- 2016: 31% of Medicare population in Part C

Question:
13. Medicaid
Answer:
- Waivers under the Social Security Act
- Balanced Budget Act of 1997 gave states authority to enroll beneficiaries in managed care without
waivers
- Over 75% are enrolled in managed care plans nationwide

Question:
14. Managed care during the 1990s:
Answer:
- Limited number of providers
- Control over utilization and limits on reimbursement

Question:
15. Managed care during the 1990s compromise:

, Answer:
- Utilization management was relaxed
- Multiple reimbursement method
- Increase provider choice

Question:
16. 3 main types of controls:
Answer:
- Expert evaluation = Determination least expensive service
- Review the course of medical treatment

Question:
17. Utilization of inpatient services takes priority
Answer:
- Gatekeeping
- Utilization review

Question:
18. Gatekeeping
Answer:
= Commonly used by HMOs
- PCP coordinated all health services
- Emphasizes preventative care, routine physical exams, and other primary care services
- Make referral for specialty reviews

Question:
19. Utilization review
Answer:
- Evaluate services provided
- Three types: prospective, concurrent, and retrospective

Question:
20. Prospective utilization review
Answer:
Prevents unnecessary or inappropriate institutionalization or treatments

Question:
21. Concurrent utilization review
Answer:
- Review during the course of health care utilization
- Discharge planning and concurrent review go hand in hand

Question:
22. Retrospective utilization review
Answer:
- Review utilization after services have already been delivered
- Overutilization or underutilization are examined