Podcast
Questions and Answers
What is a primary feature commonly associated with managed care?
What is a primary feature commonly associated with managed care?
Which of the following describes the role of gatekeepers in managed care?
Which of the following describes the role of gatekeepers in managed care?
Which of these statements about ERISA preemption is true?
Which of these statements about ERISA preemption is true?
What is vicarious liability in the context of managed care?
What is vicarious liability in the context of managed care?
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Which of the following is a common requirement under mandated grievance laws?
Which of the following is a common requirement under mandated grievance laws?
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What do any willing provider state laws generally facilitate?
What do any willing provider state laws generally facilitate?
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Under tort liability, what can managed care organizations be held accountable for?
Under tort liability, what can managed care organizations be held accountable for?
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Which statement about the theories available for litigation against ACOs is accurate?
Which statement about the theories available for litigation against ACOs is accurate?
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What is the primary concern of the court regarding nonprofit asset sales?
What is the primary concern of the court regarding nonprofit asset sales?
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Which aspect is highlighted as potentially undervalued when a nonprofit transfers to a for-profit sector?
Which aspect is highlighted as potentially undervalued when a nonprofit transfers to a for-profit sector?
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What do Certificates of Need (CON) aim to prevent?
What do Certificates of Need (CON) aim to prevent?
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What is a potential negative consequence of requiring Certificates of Need?
What is a potential negative consequence of requiring Certificates of Need?
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What is a major consideration when deciding between 'mission or margin' for nonprofits?
What is a major consideration when deciding between 'mission or margin' for nonprofits?
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What challenge does the Board of a nonprofit face compared to the Attorney General?
What challenge does the Board of a nonprofit face compared to the Attorney General?
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Why might hospitals seek to expand if they are not filling their beds?
Why might hospitals seek to expand if they are not filling their beds?
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What was a concern regarding the federal government's initial involvement in CON regulations?
What was a concern regarding the federal government's initial involvement in CON regulations?
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What was the primary reason Williams stopped prescribing medications for weight loss?
What was the primary reason Williams stopped prescribing medications for weight loss?
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What is the standard for court review of administrative orders as outlined?
What is the standard for court review of administrative orders as outlined?
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In the context of the discussion, what should the licensing board avoid doing?
In the context of the discussion, what should the licensing board avoid doing?
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What did the expert witnesses testify regarding the physician's practice?
What did the expert witnesses testify regarding the physician's practice?
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What was the outcome of the Hoover case regarding the board's decision?
What was the outcome of the Hoover case regarding the board's decision?
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What criticism was directed towards the experts testifying against Hoover?
What criticism was directed towards the experts testifying against Hoover?
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What was the primary focus of disagreement among expert physicians in the Hoover case?
What was the primary focus of disagreement among expert physicians in the Hoover case?
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How did the board's actions in the Hoover case affect its credibility?
How did the board's actions in the Hoover case affect its credibility?
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What is the primary reason uninsured individuals tend to avoid preventive care?
What is the primary reason uninsured individuals tend to avoid preventive care?
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Which of the following groups is at the highest risk of being uninsured?
Which of the following groups is at the highest risk of being uninsured?
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Which term describes the tendency for insured individuals to utilize more healthcare services than they would without insurance?
Which term describes the tendency for insured individuals to utilize more healthcare services than they would without insurance?
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Why do many part-time or seasonal workers remain uninsured?
Why do many part-time or seasonal workers remain uninsured?
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What is the most common reason that leads to individuals being 'underinsured'?
What is the most common reason that leads to individuals being 'underinsured'?
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How many people per year die due to a lack of insurance?
How many people per year die due to a lack of insurance?
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What is one significant effect of lacking early diagnosis in uninsured individuals?
What is one significant effect of lacking early diagnosis in uninsured individuals?
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What percentage of non-elderly uninsured Americans live in households with at least one full-time employee?
What percentage of non-elderly uninsured Americans live in households with at least one full-time employee?
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What significant change occurred in Switzerland's health care system in the 90s?
What significant change occurred in Switzerland's health care system in the 90s?
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How did the fixed benefit packages in Switzerland affect insurance companies?
How did the fixed benefit packages in Switzerland affect insurance companies?
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What is one of the limits imposed on insurance companies in the Swiss health care system?
What is one of the limits imposed on insurance companies in the Swiss health care system?
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What was one of the stumbling blocks to health care reform in the U.S.?
What was one of the stumbling blocks to health care reform in the U.S.?
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Why are drug prices lower in Switzerland compared to the U.S.?
Why are drug prices lower in Switzerland compared to the U.S.?
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Which characteristic of the U.S. health care system contrasts most with Switzerland's model?
Which characteristic of the U.S. health care system contrasts most with Switzerland's model?
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What could be a reason why Americans are generally less healthy than citizens of other countries?
What could be a reason why Americans are generally less healthy than citizens of other countries?
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Which of the following is NOT a theme from foreign health care systems as mentioned?
Which of the following is NOT a theme from foreign health care systems as mentioned?
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What is one potential bias related to practice guidelines mentioned in the content?
What is one potential bias related to practice guidelines mentioned in the content?
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Which of the following is NOT an aim of the ACA as stated in the content?
Which of the following is NOT an aim of the ACA as stated in the content?
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How does consumer-driven medicine aim to reduce waste in the healthcare system?
How does consumer-driven medicine aim to reduce waste in the healthcare system?
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What is one of the strategies aimed at improving healthcare quality mentioned in the content?
What is one of the strategies aimed at improving healthcare quality mentioned in the content?
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What is a key goal of comparative effectiveness research (CER) as noted in the content?
What is a key goal of comparative effectiveness research (CER) as noted in the content?
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What payment model is criticized for not effectively improving healthcare quality?
What payment model is criticized for not effectively improving healthcare quality?
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Which of the following tactics is used to coordinate and integrate the delivery of care?
Which of the following tactics is used to coordinate and integrate the delivery of care?
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What is one of the identified purposes of disclosing provider performance?
What is one of the identified purposes of disclosing provider performance?
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Study Notes
Chapter 1: Cost, Quality, Access & Choice
- Pure waste: spending healthcare dollars on treatments with no proven benefit (e.g., antibiotics for viral infections)
- Net waste: healthcare procedures whose benefits don't justify the costs
- Issues with defensive medicine: Providers order more procedures to avoid lawsuits, contributing to overall costs
- Medical error is a major concern, resulting in significant mortality rates and costly consequences
- Comparative effectiveness research (CER): aims to identify the most effective and efficient treatments, reducing unnecessary costs and improving quality
ACA Aims/Goals and Strategies
- ACA strategies focus on improving healthcare outcomes, efficiency, and patient-centered care
- Aims to increase access, quality, and control the costs for all populations
- Includes improvements in payment policies and reducing disparities in healthcare across populations
Access
- Many people lack health insurance, leading to decreased access to care and higher costs when they do seek care.
- Identifying problems like the "underinsured," or those with high-deductible plans that lead to insufficient access to care, are common problems with access to healthcare.
Insurance
- The cost of health insurance is a significant concern, impacting many people's ability to afford coverage.
- "Underinsured" individuals have insurance, yet high deductibles or limited coverage, making quality and cost of care a concern.
- Health insurance policies usually have preexisting conditions clauses in them which exclude people with preexisting condition or preexisting conditions to receive healthcare coverage until they have a sufficient waiting period, which impacts many people's access to insurance.
Managed Care
- Distinguishing features of managed care organizations (MCOs): risk-sharing, administrative oversight, preferred providers lists
- Types of managed care organizations (MCOs): HMOs, POSs (Point of Service) and PPOs (Preferred Provider Organizations), that are increasingly structuring provider relationships.
- Emphasis on preventative care, and/or quality over quantity of care that leads to greater potential health care expenses.
Cost
- Healthcare costs in the U.S. are significantly higher than in other developed countries.
- Administrative costs in the insurance industry contribute to overall healthcare expenses.
- Population demographics, including aging populations and prevalence of chronic conditions, impact healthcare costs.
- Costs associated with technological advancements, big pharma, and the changing nature of diseases, are significant contributors to healthcare expenses.
- Hospitals are impacted by costs because of certificates of needs in order to acquire major medical equipment and expansion of hospital facilities.
Chapter 13: The Structure of the Health Care Entities
- Different models for organizing healthcare entities: Independent Practice Associations (IPAs), Physician-Hospital Organizations (PHOs), Multi-Specialty Group Practices (MSGPs), Management Service Organizations (MSOs), Integrated Delivery Systems (IDSs).
Chapter 12: Professional Relationships
- Staff privileges and hospital-physician relationships is an important component that regulates healthcare facility operations regulated at the state and federal levels.
Chapter 14 and 15: Tax Exempt and Fraud and Abuse
- Federal tax-exempt entities providing health care services are granted certain protections that other organizations might not have.
- Fraud and abuse is possible through billing for unnecessary care, billing for services not rendered, receiving payments for services that did not occur, and/or receiving payments for higher than fair market rates or in excess of what is standard.
Chapter 12: Professional Relationships
- The importance of hospital privileges in setting the terms of employment, and the process by which an entity can regulate activities of employees that are deemed as falling outside the intended range of their jobs, in this case physicians.
Chapter 11: Quality Control
- The role of private accreditation, such as the Joint Commission, is significant in setting standards for healthcare quality.
Chapter 2: Licensing
- State-level regulation of healthcare providers, including licensing and malpractice issues is an important component to maintain healthcare.
Chapter 10: Regulation of Insurance and Managed Care
- Managed care often uses utilization review and gatekeepers, impacting patient access to care.
- Tort liability involves holding organizations (i.e., HMOs and MCOs) accountable for actions of their members, and involves both contractual and tort liability theories. Different states have different laws related to regulating healthcare policies that shape the market and practices through regulations or lack thereof. Regulation in this industry is complex.
Chapter 8 and 9: Employee Benefits and ERISA
- ERISA preempts some state laws regulating employee benefit plans, impacting how states can regulate insurance.
- There are many legal intricacies that shape whether a benefit/plan is covered under ERISA or not.
- A wide variety of remedies are available to someone impacted by a violation of an ERISA plan.
Supplementary (other topics)
- Healthcare access is a constant struggle in the US. Several topics like preventative care, different approaches to healthcare for the public, patient safety, and the costs/benefits of various models exist within the US healthcare system that merit additional study.
- Legal trends and issues will impact future healthcare practices. More knowledge about emerging health concerns, or policy issues in healthcare is important.
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Description
Test your understanding of key concepts and legal implications related to managed care. This quiz covers topics such as gatekeepers, ERISA preemption, and the legal responsibilities of managed care organizations. Perfect for healthcare professionals and students delving into the complexities of managed care.
