Health Insurance and Managed Healthcare

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What is the main reason it was expensive to process a large number of 'small' claims?

Pharmacy Benefits Manager

Special processing industry (correct)

Rx benefit carve-out

High deductibles

Which health plan type had the highest enrollment in 2023?

PPO (correct)

HMO

POS

HDHP/SO

What does HMO stand for?

Point of Service plan

Health Management Organization (correct)

Preferred Provider Organization

High Deductible Health Plan

Which term is a synonym for Managed Care Organization (MCO)?

Plan Signup and view all the answers

How is 'Managed Care' broadly defined?

...involved in financing and delivery of health care Signup and view all the answers

In the context of the text, how would you describe 'Managed Care'?

An entity involved in both health care financing and delivery Signup and view all the answers

'POS' stands for:

Point of Service plan Signup and view all the answers

'HDHP/SO' stands for:

High Deductible Health Plan with Savings Option Signup and view all the answers

What did the health insurance that existed in the past protect individuals from?

Lost income Signup and view all the answers

How did Blue Cross initially operate in terms of covering hospital costs?

Required patients to pay out-of-pocket and then reimbursed them Signup and view all the answers

What was the main purpose of Blue Shield when it was established?

Organizing physicians into group practices Signup and view all the answers

How did the concept of Blue Cross and Blue Shield differ in terms of payments?

Blue Cross required pre-payment while Blue Shield reimbursed patients Signup and view all the answers

How did the need for more than one hospital arise in the context of early health insurance?

Patients wanted a choice in where to receive medical care Signup and view all the answers

What was the role of central location premiums in early health insurance?

Guaranteed payment for hospitals Signup and view all the answers

What did Blue Shield mainly focus on covering?

Physician services Signup and view all the answers

What was the main purpose behind starting Blue Cross?

Covering all a person's hospital costs Signup and view all the answers

What is the original purpose of health insurance?

To spread the financial risk of illness or injury across a large group of people Signup and view all the answers

How do prepaid prescription programs differ from the principles of health insurance?

Health insurance is based on spreading risk, while prepaid programs involve fixed costs Signup and view all the answers

What is the main objective of managed health care?

To control costs and enhance the quality of healthcare services Signup and view all the answers

How does capitation reimbursement differ from fee-for-service reimbursement?

Capitation reimburses providers based on the number of services provided, while fee-for-service pays a fixed amount per patient Signup and view all the answers

What is a key difference between managed care and consumer-driven health?

Managed care focuses on controlling costs, while consumer-driven health prioritizes patient choice Signup and view all the answers

How does managed care impact pharmacy?

It enhances collaboration between pharmacists and other healthcare providers Signup and view all the answers

Which type of reimbursement aligns with the principles of managed care organizations (MCOs)?

Paying providers a flat fee per patient regardless of services rendered Signup and view all the answers

'Why Study Private Health Insurance?' What is one reason mentioned in the text for studying private health insurance?

To understand how insurance works and how to work with insurers, patients, and providers Signup and view all the answers

What was the predominant provider reimbursement model from the 18th century through the 1980s?

Fee-for-service Signup and view all the answers

Why did the medical care system lack the incentive to lower costs under fee-for-service reimbursement?

Providers were paid their full price for each service. Signup and view all the answers

What triggered cost concerns about healthcare benefits for employers in the 1970s?

Increasing cost of healthcare benefits Signup and view all the answers

Why did insurance companies start to be more cost-conscious on behalf of their client companies in the 1970s?

To address the rising cost of healthcare benefits Signup and view all the answers

What is the evolution of managed care characterized by?

Governing of medical services provision Signup and view all the answers

Which term describes any movement away from strict payment of services towards governing medical services provision?

Managed care Signup and view all the answers

What was the motivation for insurance companies to become more cost-conscious on behalf of their client companies?

To address cost concerns about healthcare benefits Signup and view all the answers

Why did employers find healthcare benefits increasingly expensive in the 1970s?

'Healthcare costs' were rising at a significant rate. Signup and view all the answers

What is the primary purpose of Utilization Review (UR)?

To prevent inappropriate use of services Signup and view all the answers

In which situation is Peer Review most easily conducted?

In a group practice or clinic Signup and view all the answers

Why is Utilization Review considered necessary in the medical field?

Due to lack of consensus in medicine Signup and view all the answers

What is the role of peer review in a staff-model HMO?

To ensure appropriate medical practices Signup and view all the answers

Why might someone have to pay higher prices for their choice under Utilization Review?

For unnecessary procedures Signup and view all the answers

What does Peer Review primarily focus on?

Ensuring quality through physician reviews Signup and view all the answers

How does Utilization Review help guard against unacceptable variation in medical practice?

By allowing a degree of variation while preventing imprudent treatments Signup and view all the answers

Why is Peer Review challenging when providers work in different settings?

Due to difficulties coordinating and conducting reviews Signup and view all the answers