The Healthcare System Chapters 1-6
UPDATED ACTUAL Exam Questions and
CORRECT Answers
Why does containment remain an elusive goal in U.S. health services delivery? - CORRECT
ANSWER - A lack of system-wide planning, direction, and coordination leading to a
complex and inefficient system. The system as a whole doesn't lend itself to standard budgetary
methods of cost control. Individual and corporate entities within a primarily entrepreneurial
system seek to manipulate financial incentives to their own advantage without regard to the
system as a whole.
What are the two main objectives of a health care delivery system? - CORRECT
ANSWER - It must enable all citizens to obtain needed healthcare services.
It must ensure that services are cost-effective and meet certain established standards of quality.
Name the four basic components of the U.S. health care delivery system. Which role does each
play in the delivery of health care? - CORRECT ANSWER - Financing- medical services
and health care have to be paid for and funded by someone. If someone can't afford services, the
delivery of health care is halted.
Insurance- protects the insured from financial catastrophe. Regulates payments to providers
allowing for delivery of health care.
Delivery- you must have providers to deliver health care services. Lack of providers hinder
delivery.
Payment- How services are paid for affect delivery. Insurance providers determine premiums
and how much reimbursement is valid for a certain service.
What is the primary reason for employers to purchase insurance plans to provide health benefits
to their empolyees? - CORRECT ANSWER - As a fringe benefit, but also to reduce the
number of sick days and absences from work due to illness.
Why is it that, despite the public and private health insurance programs, some U.S. citizens are
without health care coverage? - CORRECT ANSWER - Some don't qualify for the public
programs because of their income, yet do not make enough to afford the private plans.
,What is managed care? - CORRECT ANSWER - A system of health care delivery that
seeks to achieve efficiency by integrating the four functions of health care delivery.
It employs mechanisms to control (manage) utilization of medical services.
It determines the price of services, and consequently how much the providers are paid.
Why is the U.S health care market referred to as "imperfect"? - CORRECT ANSWER -
Because prices are set by agencies external to the market, they are not governed by the
unencumbered forces of supply and demand like it would be in a free market.
Discuss the intermediary role of insurance in the delivery of health care. - CORRECT
ANSWER - Health insurance is the primary means of ensuring access. Insurance decides
what services are covered and how much providers are paid for services.
Who are the major players in the U.S. health services system? What are the positive and negative
effects of the often conflicting self-interests of these players? - CORRECT ANSWER -
Physicians, health service institution administrators, insurance companies, large employers and
the government.
Self-interests create competing forces within the system causing cost containment and achieving
comprehensive system-wide reform to become nearly impossible.
Which main role does the government play in the U.S. health services system? - CORRECT
ANSWER - They determine public-sector expenditures and reimbursement rates for
services provided to Medicare, Medicaid, and CHIP beneficiaries. Formulates standards of
participation through health policy and regulation, meaning providers must comply with the
standards established by the government to be certified to provide services to these beneficiaries.
Certification standards are regarded as minimum standards of quality in most sectors of the
health care industry.
They finance 48% of total health care expenditures.
Why is it important for health care managers and policymakers to understand the intricacies of
the health care delivery system? - CORRECT ANSWER - They must understand the
macro environment in which they make critical planning and management decisions. Such
decisions will ultimately affect the efficiency and quality of services delivered.
,What is the difference between national health insurance (NHI) and a national health system
(NHS)? - CORRECT ANSWER - With NHI, the government finances health care through
general taxes, but the care is delivered by private providers. Tighter consolidation of financing,
insurance and payment features of quad-function model. Delivery detached private
arrangements.
With NHS, in addition to financing a tax-supported NHI program, the government manages the
infrastructure for delivery of medical care. Government operates most of the country's medical
institutions. Most health care providers are government employees or tightly organized in a
publicly managed infrastructure. Requires tighter consolidation of all four functions.
What is socialized health insurance (SHI)? - CORRECT ANSWER - A system where
government-mandated contributions from employers and employees finance healthcare. Private
not-for-profit insurance companies, called sickness funds, are responsible for collecting the
contributions and paying hospitals and physicians.
Provide a general overview of the Affordable Care Act. What is the main goal? - CORRECT
ANSWER - "rolled out gradually starting in 2010 when insurance companies were
mandated to start covering children and young adults below the age of 26..... mandate for
employers to provide health insurance, which is postponed until 2015....requires that all US
citizens and legal residents must be covered by either public or private insurance. The law also
relaxed standards to qualify additional numbers of people for Medicaid.... Federal subsidies have
been made available to people with incomes up to 400% of the federal poverty level to partially
offset the cost of health insurance....The law mandates insurance plans to cover a variety of
services referred to as "essential health benefits."...by its own design, the ACA would fail to
achieve universal cover-age that would enable all citizens and legal residents to have health
insurance.
"The main goal of the ACA is to increase access to health care and make it more affordable,
mainly for those who were previously uninsured."
access - CORRECT ANSWER - The ability of an individual to obtain health care services
when needed.
administrative costs - CORRECT ANSWER - costs associated with billing, collections,
bad debts, and maintaining medical records.
, balance bill - CORRECT ANSWER - Refers to the leftover sum that a provider bills to the
patient after insurance has only partially paid the charge that was initially billed.
defensive medicine - CORRECT ANSWER - Excessive medical tests and procedures
performed as a protection against malpractice lawsuits, otherwise regarded as unnecessary.
demand - CORRECT ANSWER - the quantity of health care purchased
enrollee - CORRECT ANSWER - An individual enrolled in a health plan and therefore
entitled to receive health services the plan provides.
free market - CORRECT ANSWER - patients and providers act independently, with
patients able to choose services from any provider. Prices are governed by the free and
unencumbered interaction of the forces of supply and demand.
global budget - CORRECT ANSWER - Used to control costs in centrally managed
systems. System wide healthcare expenditures are budgeted. Resources are allocated within the
budgetary limits. Availability of services and payments to providers are subject to such
budgetary constraints.
health care reform - CORRECT ANSWER - The expansion of health insurance to cover
the uninsured.
health plan - CORRECT ANSWER - The contractual arrangement between the MCO and
the enrollee, including the collective array of covered health services that the enrollee is entitled
to.
managed care - CORRECT ANSWER - A system that combines the financing and the
delivery of appropriate, cost-effective health care services to its members.
Medicaid - CORRECT ANSWER - A health care payment program sponsored by federal
& state governments for the indignant.
UPDATED ACTUAL Exam Questions and
CORRECT Answers
Why does containment remain an elusive goal in U.S. health services delivery? - CORRECT
ANSWER - A lack of system-wide planning, direction, and coordination leading to a
complex and inefficient system. The system as a whole doesn't lend itself to standard budgetary
methods of cost control. Individual and corporate entities within a primarily entrepreneurial
system seek to manipulate financial incentives to their own advantage without regard to the
system as a whole.
What are the two main objectives of a health care delivery system? - CORRECT
ANSWER - It must enable all citizens to obtain needed healthcare services.
It must ensure that services are cost-effective and meet certain established standards of quality.
Name the four basic components of the U.S. health care delivery system. Which role does each
play in the delivery of health care? - CORRECT ANSWER - Financing- medical services
and health care have to be paid for and funded by someone. If someone can't afford services, the
delivery of health care is halted.
Insurance- protects the insured from financial catastrophe. Regulates payments to providers
allowing for delivery of health care.
Delivery- you must have providers to deliver health care services. Lack of providers hinder
delivery.
Payment- How services are paid for affect delivery. Insurance providers determine premiums
and how much reimbursement is valid for a certain service.
What is the primary reason for employers to purchase insurance plans to provide health benefits
to their empolyees? - CORRECT ANSWER - As a fringe benefit, but also to reduce the
number of sick days and absences from work due to illness.
Why is it that, despite the public and private health insurance programs, some U.S. citizens are
without health care coverage? - CORRECT ANSWER - Some don't qualify for the public
programs because of their income, yet do not make enough to afford the private plans.
,What is managed care? - CORRECT ANSWER - A system of health care delivery that
seeks to achieve efficiency by integrating the four functions of health care delivery.
It employs mechanisms to control (manage) utilization of medical services.
It determines the price of services, and consequently how much the providers are paid.
Why is the U.S health care market referred to as "imperfect"? - CORRECT ANSWER -
Because prices are set by agencies external to the market, they are not governed by the
unencumbered forces of supply and demand like it would be in a free market.
Discuss the intermediary role of insurance in the delivery of health care. - CORRECT
ANSWER - Health insurance is the primary means of ensuring access. Insurance decides
what services are covered and how much providers are paid for services.
Who are the major players in the U.S. health services system? What are the positive and negative
effects of the often conflicting self-interests of these players? - CORRECT ANSWER -
Physicians, health service institution administrators, insurance companies, large employers and
the government.
Self-interests create competing forces within the system causing cost containment and achieving
comprehensive system-wide reform to become nearly impossible.
Which main role does the government play in the U.S. health services system? - CORRECT
ANSWER - They determine public-sector expenditures and reimbursement rates for
services provided to Medicare, Medicaid, and CHIP beneficiaries. Formulates standards of
participation through health policy and regulation, meaning providers must comply with the
standards established by the government to be certified to provide services to these beneficiaries.
Certification standards are regarded as minimum standards of quality in most sectors of the
health care industry.
They finance 48% of total health care expenditures.
Why is it important for health care managers and policymakers to understand the intricacies of
the health care delivery system? - CORRECT ANSWER - They must understand the
macro environment in which they make critical planning and management decisions. Such
decisions will ultimately affect the efficiency and quality of services delivered.
,What is the difference between national health insurance (NHI) and a national health system
(NHS)? - CORRECT ANSWER - With NHI, the government finances health care through
general taxes, but the care is delivered by private providers. Tighter consolidation of financing,
insurance and payment features of quad-function model. Delivery detached private
arrangements.
With NHS, in addition to financing a tax-supported NHI program, the government manages the
infrastructure for delivery of medical care. Government operates most of the country's medical
institutions. Most health care providers are government employees or tightly organized in a
publicly managed infrastructure. Requires tighter consolidation of all four functions.
What is socialized health insurance (SHI)? - CORRECT ANSWER - A system where
government-mandated contributions from employers and employees finance healthcare. Private
not-for-profit insurance companies, called sickness funds, are responsible for collecting the
contributions and paying hospitals and physicians.
Provide a general overview of the Affordable Care Act. What is the main goal? - CORRECT
ANSWER - "rolled out gradually starting in 2010 when insurance companies were
mandated to start covering children and young adults below the age of 26..... mandate for
employers to provide health insurance, which is postponed until 2015....requires that all US
citizens and legal residents must be covered by either public or private insurance. The law also
relaxed standards to qualify additional numbers of people for Medicaid.... Federal subsidies have
been made available to people with incomes up to 400% of the federal poverty level to partially
offset the cost of health insurance....The law mandates insurance plans to cover a variety of
services referred to as "essential health benefits."...by its own design, the ACA would fail to
achieve universal cover-age that would enable all citizens and legal residents to have health
insurance.
"The main goal of the ACA is to increase access to health care and make it more affordable,
mainly for those who were previously uninsured."
access - CORRECT ANSWER - The ability of an individual to obtain health care services
when needed.
administrative costs - CORRECT ANSWER - costs associated with billing, collections,
bad debts, and maintaining medical records.
, balance bill - CORRECT ANSWER - Refers to the leftover sum that a provider bills to the
patient after insurance has only partially paid the charge that was initially billed.
defensive medicine - CORRECT ANSWER - Excessive medical tests and procedures
performed as a protection against malpractice lawsuits, otherwise regarded as unnecessary.
demand - CORRECT ANSWER - the quantity of health care purchased
enrollee - CORRECT ANSWER - An individual enrolled in a health plan and therefore
entitled to receive health services the plan provides.
free market - CORRECT ANSWER - patients and providers act independently, with
patients able to choose services from any provider. Prices are governed by the free and
unencumbered interaction of the forces of supply and demand.
global budget - CORRECT ANSWER - Used to control costs in centrally managed
systems. System wide healthcare expenditures are budgeted. Resources are allocated within the
budgetary limits. Availability of services and payments to providers are subject to such
budgetary constraints.
health care reform - CORRECT ANSWER - The expansion of health insurance to cover
the uninsured.
health plan - CORRECT ANSWER - The contractual arrangement between the MCO and
the enrollee, including the collective array of covered health services that the enrollee is entitled
to.
managed care - CORRECT ANSWER - A system that combines the financing and the
delivery of appropriate, cost-effective health care services to its members.
Medicaid - CORRECT ANSWER - A health care payment program sponsored by federal
& state governments for the indignant.
