Phlt 313 Exam 3 (Dr. Lin Updated Actual Questions And Correct Answers

PHLT 313 EXAM 3 (DR. LIN UPDATED ACTUAL
QUESTIONS AND CORRECT ANSWERS

Question:
1. Module 3.1 (Ch.9) Objectives
Answer:
- Explain the functions of managed care and integrated systems
- Describe the evolution of managed care in the US
- Explain how managed care control the utilization of health care services
- Describe the different type of manage care plans
- Explain how managed care impact the access, cost and quality of health care
- Explain the meaning and different types of intergraded systems

Question:
2. Managed Care and Integrated Systems Introduction
Answer:
- Single most dominant force in US health care delivery
- Unprecedented success
- Cost control
- Large buying power:
• Enrolling a large segment of the insured population
• Taking responsibility to procure cost-effective health care for enrollees
- Organizational consolidation and formation of alliances
- New organizational arrangements

Question:
3. What is Managed Care?
Answer:
- Mechanism of providing health care services where a single organization takes on the management of:
• Financing
• Insurance
• Delivery
• Payment
- MCOs exercise formal control over the utilization of health care services

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

Question:
5. Capitation

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

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

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

Question:
8. Accreditation and Quality Indicators
Answer:
Accreditations set standards to measure performance
- National Committee for Quality Assurance (NCQA )
- The Centers for Medicare and Medicaid Services (CMS)
• Rates Medicare Advantage (Part C) plans

Question:
9. Evolution and Growth of Managed Care
Answer:
- Early 1900s: railroad, mining, and lumber companies
- 1929: First private health insurance plan: Baylor University Hospital
- 1940s: Large health plans emerged in the US
- 1973: The Health Maintenance Organization Act
- 1980s: Slow growth, but health care costs continued to rise
- Creation of other forms of managed care plans

Question:
10. Growth and Transformation of Managed Care
Answer:
- Medicare
- Medicaid

Question:
11. Medicare
Answer:
- Medicare Advantage (MA) 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:
12. 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:
13. Managed Care Today
Answer:
Different than the original form
- During the 1990s:
• Limited number of providers
• Control over utilization and limits on reimbursement
- Compromise:
• Utilization management was relaxed
• Multiple reimbursement method
• Increase provider choice

Question:
14. Three main types of controls (Utilization Control Method)
Answer:
- Expert evaluation
- Determination least expensive service
- Review the course of medical treatment

Question:
15. Utilization management of inpatient services takes priority (Utilization Control Method)
Answer:
- Gatekeeping
- Utilization Review

Question:
16. Gatekeeping (Utilization Control Method)
Answer:
- Commonly used by HMOs
- PCP coordinates all health services
- Emphasizes preventive care, routine physical examinations, and other primary care services
- Make referral for specialty services

Question:
17. Utilization review (Utilization Control Method)
Answer:
- Evaluate services provided
- Three types: prospective , concurrent, retrospective

, Question:
18. Prospective Utilization Review (Utilization Control Method)
Answer:
Prevent unnecessary or inappropriate institutionalization or treatments

Question:
19. Concurrent Utilization Review (Utilization Control Method)
Answer:
- Review during the course of health care utilization
- Discharge planning and concurrent review go hand in hand

Question:
20. Retrospective Utilization Review (Utilization Control Method)
Answer:
- Review utilization after services have already been delivered
- Overutilization or underutilization are examined

Question:
21. Three main factors led to the development of different types of managed care plans (Types of Managed
Care Plans)
Answer:
- Choice of providers
- Different ways of arranging services
- Payment and risk-sharing

Question:
22. Different types of managed care plans
Answer:
- HMO plans
- PPO plans
- POS plans

Question:
23. Health Maintenance Organization (HMO) Plans
Answer:
- First type of managed care plans on the market
- Focus on wellness care
- Four common HMO models
• Staff Model
• Group Model
• Network Model
• Independent Practice Association Model

Question:
24. Preferred Provider Organization (PPO) Plans