Questions and Answers
What is one aspect in which managed care differs from conventional insurance?
Responsibility for delivery of services
The CMS uses which of the following as an overall measure of a health plan's quality?
A star rating system
What was the consumers' main gripe against managed care during the 1990s?
Lack of choice of providers
In which type of utilization management is a primary care physician's opinion necessary in referring or not referring a patient to a specialist?
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Precertification is associated with which type of utilization review?
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In which of the following plans can an MCO lose a large number of physicians if a contract is lost?
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Most Medicare beneficiaries receive their health care through managed care plans.
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A PPO plan is a hybrid between HMO and POS plans.
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Research shows that there are issues with access to both primary and specialty care in Medicaid managed care.
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Explain how the rise of HMOs and PPOs were used in a health care cost-reduction strategy.
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Study Notes
Managed Care vs. Conventional Insurance
- Managed care differs by assuming responsibility for the delivery of services, unlike conventional insurance.
Quality Measurement in Managed Care
- The Centers for Medicare & Medicaid Services (CMS) utilizes a star rating system to evaluate the overall quality of health plans.
Consumer Concerns in the 1990s
- During the 1990s, a primary complaint from consumers regarding managed care was the restricted choice of healthcare providers.
Utilization Management: Gatekeeping
- Gatekeeping requires a primary care physician's opinion when deciding whether to refer a patient to a specialist, ensuring coordinated care.
Precertification and Utilization Review
- Precertification is linked to prospective utilization review, which evaluates the necessity of a service before it's provided.
Risk in HMO IPA Model Plans
- Managed Care Organizations (MCOs) may face significant physician losses if a contract is terminated in Health Maintenance Organization (HMO) Independent Practice Association (IPA) model plans.
Medicare Beneficiary Care
- Most Medicare beneficiaries do not receive their healthcare through managed care plans.
PPO Plan Characteristics
- The statement that Preferred Provider Organization (PPO) plans are a hybrid of HMO and Point of Service (POS) plans is incorrect.
Medicaid Managed Care Access Issues
- Research has indicated that both primary and specialty care access issues persist within Medicaid managed care systems.
Cost-Reduction Strategies with HMOs and PPOs
- Health Maintenance Organizations (HMOs) contribute to cost reduction through preventative medicine strategies, which help control expenses.
- Preferred Provider Organizations (PPOs) negotiate discounted fee arrangements with healthcare providers, achieving discounts between 25% and 35% off standard fees.
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Description
This quiz covers key concepts from Chapter 9 on managed care in health systems. Explore aspects such as differences from conventional insurance, quality measures, and consumer concerns from the 1990s. Perfect for students studying health care management or taking related courses.
