Managed Care Chapter 21

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Questions and Answers

What is an organization through which employer health benefit plans and health insurance carriers contract to purchase healthcare services for covered beneficiaries from a selected group of participating providers?

Preferred Provider Organization (correct)

Health Maintenance Organization

Exclusive Provider Organization

Managed Care Organization

What is a group practice without walls?

A physician organization formed for the purpose of sharing some administrative and management costs while continuing to practice at their own locations.

What is a review that is performed during the course of treatment referred to as?

Concurrent review

What is the purpose of the Health Care Quality Improvement Act?

To provide those persons giving information to professional review bodies and those assisting in review activities limited immunity from damages that may arise as a result of adverse decisions affecting a physician's medical staff privileges. Signup and view all the answers

What is Antitrust implication when a managed care organization possesses significant market share?

Antitrust implications can arise. Signup and view all the answers

What is a prospective review system?

A system where the payer determines whether to pay for treatment before the treatment is initiated. Signup and view all the answers

What is managed care?

The process of structuring or restructuring the healthcare system in terms of financing, purchasing, delivering, measuring, and documenting a broad range of health care services and products. Signup and view all the answers

What is a physician-hospital organization?

A legal entity consisting of a joint venture of physicians and a hospital, formed to facilitate managed care contracting. Signup and view all the answers

The Employment Retirement Income Security Act (ERISA) regulates the contents of the welfare benefit plans.

False Signup and view all the answers

According to the VA healthcare system, NC is in which veterans integrated service network (VISN)?

6th Signup and view all the answers

Which of the following is the process whereby a third-party payer evaluates the medical necessity of a course of treatment?

Utilization review Signup and view all the answers

What did Congress enact to increase the number of Americans covered by health insurance by approximately 30 million people?

Patient Protection and Affordable Care Act Signup and view all the answers

Vertically integrated delivery systems were envisioned to provide comprehensive care to patients.

True Signup and view all the answers

Match the following laws with their purpose:

Health Care Quality Improvement Act of 1986 = Provides limited immunity to professionals involved in peer review Ethics in Patient Referral Act = Prohibits certain referrals by physicians with a financial interest Employee Retirement Income Security Act of 1974 = Regulates employee benefit plans Title XIII of the Public Health Service Act = Fosters the growth of HMOs Signup and view all the answers

Which title of the ACA has not been implemented by the Secretary for Health and Human Services?

Not specified Signup and view all the answers

ERISA does not cover group health plans established or maintained by government entities or churches.

True Signup and view all the answers

Study Notes

Managed Care Concepts

Preferred Provider Program: An organization facilitating employer health benefit plans to purchase healthcare services from a select group of providers.
Group Practice Without Walls: A physician organization helping to share administrative costs while allowing physicians to continue practice at their own locations.

Reviews and Regulations

Concurrent Review: A treatment evaluation conducted during the course of treatment.
Utilization Review: Process by which third-party payers assess the necessity of a treatment course.
Health Care Quality Improvement Act: Provides limited immunity to individuals giving information to professional review bodies regarding adverse effects on physician staff privileges.

Market Dynamics

Patient Protection and Affordable Care Act (ACA): Enacted by Congress, resulting in coverage for approximately 30 million Americans and reducing insurance costs.
Antitrust Implications: Arise when managed care organizations have significant market share, with potential violations related to price fixing.

Healthcare Delivery Systems

Physician-Hospital Organization: Joint venture between physicians and hospitals aimed at improving cost management and expanding community healthcare resources.
Vertically Integrated Delivery System: Provides a range of services from primary outpatient to tertiary inpatient care.

Health Insurance Plan Types

Prospective Review System: A payer decides on treatment reimbursement before it is provided.
Types of Managed Care Plans:
- Point of Service Plans: Utilize primary care physicians as gatekeepers to manage healthcare.
- Exclusive Provider Organization: Limits beneficiaries to participating providers for all healthcare services.
- Specialty HMOs: Offer limited healthcare coverage components, often focusing on specific areas like dental.
- Independent Practice Association: A legal entity of physicians negotiating contracts for services.

Legal and Regulatory Framework

Employee Retirement Income Security Act (ERISA): Does not cover government or church health plans, nor those maintaining compliance solely with worker's compensation or disability laws.
Stark Law: Prohibits physician referrals to clinical laboratories if they have ownership interests or compensation arrangements with those labs.

Other Notable Points

NC in Veterans Integrated Service Network (VISN): North Carolina is part of the 6th VISN according to the VA healthcare system.
Titles of the ACA: There are ten titles associated with the ACA, with some not implemented by the Secretary for Health and Human Services.

True or False Statements

Vertically Integrated Delivery Systems: Designed to deliver comprehensive care from primary to long-term care facilities, sometimes including insurance components.
ERISA's Scope: True that ERISA does not cover certain group health plans established by governmental or church entities.

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Description

This quiz covers key concepts from Chapter 21 on Managed Care and National Resources. Understand terms like preferred provider program and the organization of medical practices. Test your knowledge and retention of essential healthcare management concepts.