USHCS Chapter 9 Questions With Complete Solutions
(Blank) are found to be more efficient in MCO environments.
Correct Answers Hospitals
Accreditation came in response to: Correct Answers The
demand for standardized, objective information about the quality
of MCOs.
Balancing power on the demand and supply sides of the health
care market led to: Correct Answers Organizational
integration.
Control costs by sharing (blank) or extracting (blank). Correct
Answers Risks; discounts
Explain "patient protection laws."
Explain "any willing provider laws."
Think: What were their roles in the MCO backlash? Correct
Answers Patient Protection Laws = perhaps directly
responsible for MCOs backing off.
Any Willing Provider Laws = as long as they abide by the
networks terms and conditions, the provider will be admitted
into the network.
Explain accountable care organizations (ACOs). Correct
Answers Integrated group of providers who are willing/able to
take responsibility for improving the health status, care
efficiency, and satisfaction with care for defined population.
,Two pronged approach: financial incentives form ACOs of
providers. Medicare assigns patients to an ACO where they
receive all needed services.
Higher quality, modest savings.
ACOs with MCO contracts produce better value in the private
market.
Explain care coordination. Correct Answers Achieve
integrated, interdisciplinary services while overcoming
discontinuities in care delivery.
Explain case management. Correct Answers Organized
approach to evaluating and coordinating care, particularly for
patients who have complex, potentially costly problems that
require many different services from many different providers
over an extended period.
Need expensive secondary/tertiary care vs. primary care.
Based on patient's changing needs, services are arranged so they
are delivered in the most appropriate and cost-effective settings.
Explain choice of restriction.
Explain panels, open panels, and closed panels. Correct
Answers Patients still choose, but they must choose physicians
who are employed by/contract with the MCO.
Panel = physicians who have formal affiliations with the MCO.
Open Panel = allows access to providers outside the plan, but
they have higher out-of-pocket costs.
Closed Panel = services obtained outside the plan are not
covered; better manager of utilization.
, Explain disease management. Correct Answers Used primarily
by health plans, a population-oriented strategy involving patient
education, training in self-management, ongoing monitoring of
the disease process, and follow-up aimed at people with chronic
conditions (diabetes, asthma, depression, coronary artery
disease, etc.).
"Self-care with professional support"
Prevent/delay, comorbidities/complications from uncontrolled
chronic condition. Improve quality of care and disease control;
adds to quality of life.
Explain gatekeeping. Correct Answers PCP must refer you to
a specialist before you can obtain specialist services.
Results in modest cost savings.
Explain health maintenance organizations (HMOs). Correct
Answers Provided medical care during illness, but also a
variety of services to help people maintain their health; ACA got
rid of this distinction.
Choose physician from panel.
Providers receive capitated fees.
Must obtain care from in-network hospitals, physicians, and
other providers.
Specialty services are carved out (carve-out = assignment
through contractual arrangement of specialized services to an
outside organization because the services are not included in the
contracts that the MCO has with its providers or the MCO does
not provide the services).
Ensures services comply with quality standards.
(Blank) are found to be more efficient in MCO environments.
Correct Answers Hospitals
Accreditation came in response to: Correct Answers The
demand for standardized, objective information about the quality
of MCOs.
Balancing power on the demand and supply sides of the health
care market led to: Correct Answers Organizational
integration.
Control costs by sharing (blank) or extracting (blank). Correct
Answers Risks; discounts
Explain "patient protection laws."
Explain "any willing provider laws."
Think: What were their roles in the MCO backlash? Correct
Answers Patient Protection Laws = perhaps directly
responsible for MCOs backing off.
Any Willing Provider Laws = as long as they abide by the
networks terms and conditions, the provider will be admitted
into the network.
Explain accountable care organizations (ACOs). Correct
Answers Integrated group of providers who are willing/able to
take responsibility for improving the health status, care
efficiency, and satisfaction with care for defined population.
,Two pronged approach: financial incentives form ACOs of
providers. Medicare assigns patients to an ACO where they
receive all needed services.
Higher quality, modest savings.
ACOs with MCO contracts produce better value in the private
market.
Explain care coordination. Correct Answers Achieve
integrated, interdisciplinary services while overcoming
discontinuities in care delivery.
Explain case management. Correct Answers Organized
approach to evaluating and coordinating care, particularly for
patients who have complex, potentially costly problems that
require many different services from many different providers
over an extended period.
Need expensive secondary/tertiary care vs. primary care.
Based on patient's changing needs, services are arranged so they
are delivered in the most appropriate and cost-effective settings.
Explain choice of restriction.
Explain panels, open panels, and closed panels. Correct
Answers Patients still choose, but they must choose physicians
who are employed by/contract with the MCO.
Panel = physicians who have formal affiliations with the MCO.
Open Panel = allows access to providers outside the plan, but
they have higher out-of-pocket costs.
Closed Panel = services obtained outside the plan are not
covered; better manager of utilization.
, Explain disease management. Correct Answers Used primarily
by health plans, a population-oriented strategy involving patient
education, training in self-management, ongoing monitoring of
the disease process, and follow-up aimed at people with chronic
conditions (diabetes, asthma, depression, coronary artery
disease, etc.).
"Self-care with professional support"
Prevent/delay, comorbidities/complications from uncontrolled
chronic condition. Improve quality of care and disease control;
adds to quality of life.
Explain gatekeeping. Correct Answers PCP must refer you to
a specialist before you can obtain specialist services.
Results in modest cost savings.
Explain health maintenance organizations (HMOs). Correct
Answers Provided medical care during illness, but also a
variety of services to help people maintain their health; ACA got
rid of this distinction.
Choose physician from panel.
Providers receive capitated fees.
Must obtain care from in-network hospitals, physicians, and
other providers.
Specialty services are carved out (carve-out = assignment
through contractual arrangement of specialized services to an
outside organization because the services are not included in the
contracts that the MCO has with its providers or the MCO does
not provide the services).
Ensures services comply with quality standards.
