Healthcare delivery systems, regulations and
compliance UPDATED Exam Questions
and CORRECT Answers
What? - CORRECT ANSWER - What shaped US healthcare?
How did health insurance emerge?
How does legislation affect healthcare?
What do regulatory agencies do?
What is the purpose of accreditation and certification?
What is the role of consumer protection?
How can competition in healthcare benefit patients?
What divides federal and state responsibility?
Why? - CORRECT ANSWER - Understanding and contextualizing the current healthcare
landscape will help healthcare managers anticipate and adapt to changes in the landscape.
How? - CORRECT ANSWER - Essentials of US Health Care System; Chapters 1-3, 6, 12
and 13
Medicare Program - General Information
Summary of the Affordable Care Act
Additional Health IT Regulations and Regulatory Guidance
About HHS
HHS Regulations
Chapter 1 - CORRECT ANSWER -
Subsystems of US Health Care Delivery - CORRECT ANSWER - Managed Care
Military
,Special Populations
Integrated Delivery
Long Term Care Delivery
Public Health System
Managed Care - CORRECT ANSWER - 1) Seeks to achieve efficiency by integrating the
basic functions of health care delivery.
2) Employs mechanisms to control (manage) utilization of medical services.
3) Determines the price at which the services are purchased and how provides get paid.
** dominant health care in US - covers in both private and public health insurance programs
(medicare/medicaid).
** financed primarily by employer or government - contracts with MCO such as an HMO or
PPO
- MCO negotiates with provides and pays them through a capitation (per head) arragement or a
discounted fee arrangement
MCO - CORRECT ANSWER - Managed Care Organization - functions like an insurance
company. Provides health care services contracted under the health plan to the enrollees of the
plan.
-Enrollee - individual covered under the plan
- Health plan - contractual arrangement between the MCO and enrollee - includes list of covered
health services to which enrollees are entitled
- uses selected providers - usually PCP and general practitioners who are the gate keepers
Military Medical Care System - CORRECT ANSWER - A well-organized, highly
integrated system that is comprehensive and covers preventive as well as treatment services to
active duty military personnel of the US Army, Navy, Air Force, Coast Guard, and certain
,uniformed nonmilitary services - such as Public Health Service and National Oceanographic and
Atmospheric Association (NOAA)
- Free of charge
Tricare-covers families, dependents, and retired military
-VA - for retired veterans and focuses on hospital, mental health and long-term care,
largest/oldest (1946) organized health systems in world, mission to provide medical care,
education and training, research, contingency support and emergency management for the DOD
medical care system - organized into 23 geographically-distributed Veterans Integrated Service
Networks (VISN) that coordinate their own services and receives federal funds
Subsystem for Special Populations - CORRECT ANSWER - Vulnerable Populations -
poor, uninsured, minorities and immigrants
Live in disadvantaged communities and receive care from "safety net" providers that are not
secure. Provider type and availaibility vary. Some individuals forego care and seek ER services
nearby. Providers are presured to see rising number of uninsured.
Medicare - one largest publice health insurance and serves elderly, disabled, and those with end-
stage renal disease.
Medicaid - third larges source of health insurance providing coverage for low-income adults,
children, the elderly, and individuals with disability. Largest provider for long-term care to older
americans and disabiled. CHIP provide coverage to children of adults with modest incomes who
do not qualify for medicaid.
Primary financial source for the safety net, does not allow much cost shifting.
Integrated Delivery System (IDS) - CORRECT ANSWER - Hallmark of the US health
care industry - to form integrated delivery systems.
, IDS are various forms of ownership and links among hospitals, physicians and insurers.
Objective: one HCO deliver range of services. Network of organizations that provides or
arranges to provide a coordinated continuum of services to definced populations held clinically
and fiscally accountable for outcomes and health status.
Long-term care - CORRECT ANSWER - consists of medical and nonmedical care that is
provided to individuals who are chronically ill or who have a disability By 2020 - ^ than 12
million projected to require
Public Health System - CORRECT ANSWER - 1) Monitoring health status to ID and
solve community health problems.
2) Diagnose and investigate health problems and hazards.
3) Inform and educate about health problems and hazards.
4) Mobilizing the community to solve health problems.
5) Develop policies to support individual and community health efforts.
6) Enforce laws and regulations to support health safety.
7) Providing people with access to necessary care.
8) Assuring a competent and professional health workforce.
9) Eval the effectiveness, accessibility, and quality of personal and population-based health
services.
10) Perform research to discover innovative solutions to health problems.
Main characteristics of US Health Care System - CORRECT ANSWER - 1) No central
governing agency and little integration and coordination.
2) Technology-driven delivery system focusing on acute care
3) High in cost, unequal access, and average in outcome
4) Delivery of health care under imperfect market conditions
5) Government as subsidiary to the private sector
6) Fusion of market justice and social justice
7) Multiple players and balance of power
8) Quest for integration and accountability
compliance UPDATED Exam Questions
and CORRECT Answers
What? - CORRECT ANSWER - What shaped US healthcare?
How did health insurance emerge?
How does legislation affect healthcare?
What do regulatory agencies do?
What is the purpose of accreditation and certification?
What is the role of consumer protection?
How can competition in healthcare benefit patients?
What divides federal and state responsibility?
Why? - CORRECT ANSWER - Understanding and contextualizing the current healthcare
landscape will help healthcare managers anticipate and adapt to changes in the landscape.
How? - CORRECT ANSWER - Essentials of US Health Care System; Chapters 1-3, 6, 12
and 13
Medicare Program - General Information
Summary of the Affordable Care Act
Additional Health IT Regulations and Regulatory Guidance
About HHS
HHS Regulations
Chapter 1 - CORRECT ANSWER -
Subsystems of US Health Care Delivery - CORRECT ANSWER - Managed Care
Military
,Special Populations
Integrated Delivery
Long Term Care Delivery
Public Health System
Managed Care - CORRECT ANSWER - 1) Seeks to achieve efficiency by integrating the
basic functions of health care delivery.
2) Employs mechanisms to control (manage) utilization of medical services.
3) Determines the price at which the services are purchased and how provides get paid.
** dominant health care in US - covers in both private and public health insurance programs
(medicare/medicaid).
** financed primarily by employer or government - contracts with MCO such as an HMO or
PPO
- MCO negotiates with provides and pays them through a capitation (per head) arragement or a
discounted fee arrangement
MCO - CORRECT ANSWER - Managed Care Organization - functions like an insurance
company. Provides health care services contracted under the health plan to the enrollees of the
plan.
-Enrollee - individual covered under the plan
- Health plan - contractual arrangement between the MCO and enrollee - includes list of covered
health services to which enrollees are entitled
- uses selected providers - usually PCP and general practitioners who are the gate keepers
Military Medical Care System - CORRECT ANSWER - A well-organized, highly
integrated system that is comprehensive and covers preventive as well as treatment services to
active duty military personnel of the US Army, Navy, Air Force, Coast Guard, and certain
,uniformed nonmilitary services - such as Public Health Service and National Oceanographic and
Atmospheric Association (NOAA)
- Free of charge
Tricare-covers families, dependents, and retired military
-VA - for retired veterans and focuses on hospital, mental health and long-term care,
largest/oldest (1946) organized health systems in world, mission to provide medical care,
education and training, research, contingency support and emergency management for the DOD
medical care system - organized into 23 geographically-distributed Veterans Integrated Service
Networks (VISN) that coordinate their own services and receives federal funds
Subsystem for Special Populations - CORRECT ANSWER - Vulnerable Populations -
poor, uninsured, minorities and immigrants
Live in disadvantaged communities and receive care from "safety net" providers that are not
secure. Provider type and availaibility vary. Some individuals forego care and seek ER services
nearby. Providers are presured to see rising number of uninsured.
Medicare - one largest publice health insurance and serves elderly, disabled, and those with end-
stage renal disease.
Medicaid - third larges source of health insurance providing coverage for low-income adults,
children, the elderly, and individuals with disability. Largest provider for long-term care to older
americans and disabiled. CHIP provide coverage to children of adults with modest incomes who
do not qualify for medicaid.
Primary financial source for the safety net, does not allow much cost shifting.
Integrated Delivery System (IDS) - CORRECT ANSWER - Hallmark of the US health
care industry - to form integrated delivery systems.
, IDS are various forms of ownership and links among hospitals, physicians and insurers.
Objective: one HCO deliver range of services. Network of organizations that provides or
arranges to provide a coordinated continuum of services to definced populations held clinically
and fiscally accountable for outcomes and health status.
Long-term care - CORRECT ANSWER - consists of medical and nonmedical care that is
provided to individuals who are chronically ill or who have a disability By 2020 - ^ than 12
million projected to require
Public Health System - CORRECT ANSWER - 1) Monitoring health status to ID and
solve community health problems.
2) Diagnose and investigate health problems and hazards.
3) Inform and educate about health problems and hazards.
4) Mobilizing the community to solve health problems.
5) Develop policies to support individual and community health efforts.
6) Enforce laws and regulations to support health safety.
7) Providing people with access to necessary care.
8) Assuring a competent and professional health workforce.
9) Eval the effectiveness, accessibility, and quality of personal and population-based health
services.
10) Perform research to discover innovative solutions to health problems.
Main characteristics of US Health Care System - CORRECT ANSWER - 1) No central
governing agency and little integration and coordination.
2) Technology-driven delivery system focusing on acute care
3) High in cost, unequal access, and average in outcome
4) Delivery of health care under imperfect market conditions
5) Government as subsidiary to the private sector
6) Fusion of market justice and social justice
7) Multiple players and balance of power
8) Quest for integration and accountability
