PAM FINAL EXAM | COMPLETE STUDY GUIDE, PRACTICE QUESTIONS &
ANSWERS 2026/2027
What is "primary care" and its key components? - ANS ✔✔- Primary care: care provided by
clinicians trained and skilled in first contact and continuing care for people with undiagnosed
signs, symptoms, or concerns. Not limited by problem origin, organ system, or diagnosis
- Performed by clinicians collaborating with other health professionals, providing advocacy in
the health care system to accomplish cost-effective care
- Promotes effective communication
- Patient as partner
True or false: No matter how you slice the data, higher quality of care is more expensive care. -
ANS ✔✔False
In 2010, prescription drugs were responsible for the greatest share of healthcare spending in
the US. - ANS ✔✔- False, it was hospital, physicians, then prescription drugs.
True or False: In the US, strong clinical care is the #1 driver of the wellbeing of individuals and
communities. - ANS ✔✔True
What are the three main components of the IHI "triple aim"? - ANS ✔✔- Population Health
- Experience of Care
- Per Capita Cost
What fourth component does Cornell Health incorporate to produce a "quadruple aim"? - ANS
✔✔Readiness
,Population Health Management - ANS ✔✔- accountability and management of the health of an
entire community, regardless of system membership or insurance status.
- Combines interventions that focus on patients with specific chronic conditions (disease
management) or very high cost irrespective of the cause (case management) with wellness
components aimed at using health risk assessments to identify and improve unhealthy
behaviors
key attributes of PHM - ANS ✔✔o approaches developed to foster health and quality of care
improvements while managing costs
o Addresses the preventive and chronic care needs of every patient
o organized systems of care
o coordinated care teams
o focus on upstream social determinants of health
o holistic patient centered primary care by interdisciplinary care teams
o analysis of data to identify and target high-risk/high cost patients for chronic care
management
o accountability
care coordination pyramid - ANS ✔✔- organizes patients into strata of who needs more
attention
5/50 rule - ANS ✔✔small percent of people in any given population who account for 50% of the
cost
why is 5/50 rule so important to triple aim? - ANS ✔✔- this is important because as health care
costs rise, providers are trying to find these patients and get to the root of their problem in
order to decrease cost, increase quality of care, and increase health of population overall
What is a healthcare "super utilizer?" - ANS ✔✔- high need, high cost patients who require
complex care management
, - complex physical, behavioral, and social needs are not well met through the current
fragmented health care system
- often bounce from ED to ED, inpatient admission to readmission, etc. which is costly and
ineffective
How did the Camden Coalition develop their strategy for improving outcomes and reducing
costs among super utilizers - ANS ✔✔- A doctor mapped out crime rates in relation to health
outcomes in the city and found that the most expensive patients were concentrated in the same
area.
-By focusing on this specific population that had the highest costs, they were able to focus on
getting community health workers.
camden coalition - ANS ✔✔- the strategic use of data to reallocate resources to a small subset
of high-needs, high-cost patients.
- Actively identifying sick patients and responding proactively in real time to improve health and
reduce costs.
chronic care management (CCM) - ANS ✔✔- Primary-care integrated complex care management
- specially trained, multidisciplinary teams that coordinate closely with primary care teams to
meet the needs of medically complex patients.
how does CCM target high-need/high-cost patients to improve their health, wellbeing,
functional status, and costs? - ANS ✔✔- They use predictive modelling (acute events, ED visits,
hospitalizations, etc.) to identify patients at highest risk for poor outcomes and who would
benefit from CCM.
- They try to address more than medical issues by increasing patients capacity to self-manage
condition; eliminate unnecessary clinical testing, and reduce need for acute care services
What role does trust play in CCM? - ANS ✔✔- It helps to address social factors and isolation by
visiting patients at a time of need, having culturally and linguistically concordant and
ANSWERS 2026/2027
What is "primary care" and its key components? - ANS ✔✔- Primary care: care provided by
clinicians trained and skilled in first contact and continuing care for people with undiagnosed
signs, symptoms, or concerns. Not limited by problem origin, organ system, or diagnosis
- Performed by clinicians collaborating with other health professionals, providing advocacy in
the health care system to accomplish cost-effective care
- Promotes effective communication
- Patient as partner
True or false: No matter how you slice the data, higher quality of care is more expensive care. -
ANS ✔✔False
In 2010, prescription drugs were responsible for the greatest share of healthcare spending in
the US. - ANS ✔✔- False, it was hospital, physicians, then prescription drugs.
True or False: In the US, strong clinical care is the #1 driver of the wellbeing of individuals and
communities. - ANS ✔✔True
What are the three main components of the IHI "triple aim"? - ANS ✔✔- Population Health
- Experience of Care
- Per Capita Cost
What fourth component does Cornell Health incorporate to produce a "quadruple aim"? - ANS
✔✔Readiness
,Population Health Management - ANS ✔✔- accountability and management of the health of an
entire community, regardless of system membership or insurance status.
- Combines interventions that focus on patients with specific chronic conditions (disease
management) or very high cost irrespective of the cause (case management) with wellness
components aimed at using health risk assessments to identify and improve unhealthy
behaviors
key attributes of PHM - ANS ✔✔o approaches developed to foster health and quality of care
improvements while managing costs
o Addresses the preventive and chronic care needs of every patient
o organized systems of care
o coordinated care teams
o focus on upstream social determinants of health
o holistic patient centered primary care by interdisciplinary care teams
o analysis of data to identify and target high-risk/high cost patients for chronic care
management
o accountability
care coordination pyramid - ANS ✔✔- organizes patients into strata of who needs more
attention
5/50 rule - ANS ✔✔small percent of people in any given population who account for 50% of the
cost
why is 5/50 rule so important to triple aim? - ANS ✔✔- this is important because as health care
costs rise, providers are trying to find these patients and get to the root of their problem in
order to decrease cost, increase quality of care, and increase health of population overall
What is a healthcare "super utilizer?" - ANS ✔✔- high need, high cost patients who require
complex care management
, - complex physical, behavioral, and social needs are not well met through the current
fragmented health care system
- often bounce from ED to ED, inpatient admission to readmission, etc. which is costly and
ineffective
How did the Camden Coalition develop their strategy for improving outcomes and reducing
costs among super utilizers - ANS ✔✔- A doctor mapped out crime rates in relation to health
outcomes in the city and found that the most expensive patients were concentrated in the same
area.
-By focusing on this specific population that had the highest costs, they were able to focus on
getting community health workers.
camden coalition - ANS ✔✔- the strategic use of data to reallocate resources to a small subset
of high-needs, high-cost patients.
- Actively identifying sick patients and responding proactively in real time to improve health and
reduce costs.
chronic care management (CCM) - ANS ✔✔- Primary-care integrated complex care management
- specially trained, multidisciplinary teams that coordinate closely with primary care teams to
meet the needs of medically complex patients.
how does CCM target high-need/high-cost patients to improve their health, wellbeing,
functional status, and costs? - ANS ✔✔- They use predictive modelling (acute events, ED visits,
hospitalizations, etc.) to identify patients at highest risk for poor outcomes and who would
benefit from CCM.
- They try to address more than medical issues by increasing patients capacity to self-manage
condition; eliminate unnecessary clinical testing, and reduce need for acute care services
What role does trust play in CCM? - ANS ✔✔- It helps to address social factors and isolation by
visiting patients at a time of need, having culturally and linguistically concordant and
