Chapter 9

The managed care phenomenon was welcomed mostly by: a. employers b. workers c. private insurance d. the government

With the growth of managed care, the balance of power in the medical marketplace swung toward: a. providers b. the supply side c. the demand side d. more regulation

A managed care organization functions like: a. a provider b. an insurer c. a regulator d. a financier

What is the purpose of risk sharing with providers? a. It makes providers immune to costs b. It makes providers cost conscious c. It rewards providers for quality d. It keeps insurance premiums low

Capitation is best described as: a. monthly lump sum payment regardless of utilization b. monthly lump sum payment regardless of cost c. per member per month payment d. payments capped to a maximum cost for delivering services

Under capitation, risk is shifted: a. from the insured to the employer b. from the provider to the MCO c. from the employer to the MCO d. from the MCO to the provider

Under which payment method is a fee schedule used? a. prospective payment b. capitation c. discounted fees d. fee for service

The HMO Act of 1973 required: a. health care providers to contract with HMOs b. managed care organizations to offer HMO alternatives c. insurers to switch to managed care d. employers to offer an HMO alternative to conventional health insurance

In the term, managed care, 'manage' refers to: a. management of utilization b. management of premiums c. management of risk d. management of the supply of services

Under the fee-for-service system, providers had the incentive to: a. deliver more services than what would be medically necessary because a greater volume would increase their incomes b. use less technology because they could increase their incomes by not using costly procedures c. indiscriminate cost increases because they could get paid whatever they would charge d. increase the level of quality in order to attract more patients

In the beginning, why did HMOs only had limited appeal? a. HMOs faced resistance from employers b. The shadow pricing practices used by HMOs were declared illegal c. The HMOs had only limited ability to control costs. d. The insured wanted to maintain the choice of providers

Closed-panel plan. a. No new physicians can be added to the plan b. New enrollees are not accepted by the plan c. The enrollee cannot switch from one plan to another d. The enrollee is restricted to the providers on the panel

Gatekeeping heavily depends on the services of a: a. primary care physician b. case manager c. disease consultant d. nurse practitioner

Gatekeeping emphasizes: a. denial of specialized services b. closed-panel utilization c. preventive and primary care d. secondary care

Under _____ a primary care physician becomes the portal of entry to the health care delivery system. a. case management b. utilization review c. gatekeeping d. closed-panel utilization

Cost-effective management of care for patients who have complex medical conditions. a. Case management b. Gatekeeping c. Utilization management d. Managed care

A primary care physician decides whether or not to refer a patient to a specialist. a. Preauthorization b. Prospective utilization review c. Disease management d. Closed-panel utilization

Precertification is the responsibility of: a. the gatekeeper b. the case manager c. the health plan d. the employer

Under prospective utilization review, if a case is determined to be potentially complex and costly, it is referred to: a. case management b. concurrent utilization review c. appropriate specialists d. discharge planners

Concurrent UR in a hospital will be primarily concerned with the: a. disease process b. length of stay c. preauthorizations d. quality management

Closely associated with concurrent UR is the function of: a. preauthorization b. rehabilitation c. practice profiling d. discharge planning

Review of patterns of practice is undertaken as part of: a. concurrent utilization review b. retrospective utilization review c. prospective utilization review d. case management

Data collection and statistical analysis are often part of: a. concurrent utilization review b. retrospective utilization review c. prospective utilization review d. case management

Monitoring of provider-specific practice patterns. a. concurrent utilization review b. retrospective utilization review c. case management d. practice profiling

When an MCO adopts capitation as the primary method of payment, which service is likely to be carved out? a. Specialty care b. Gatekeeping c. Mental health d. Primary care

Physicians are employees of the HMO. a. Preferred providers b. IPA model c. Staff model d. Independent practice association

Which HMO model is likely to provide the greatest control over the practice patterns of physicians? a. Staff model b. Group model c. Network model d. IPA model

In which HMO model is the choice of physicians likely to be most restricted? a. Staff model b. Group model c. Network model d. IPA model

Which HMO model is likely to require heavy capital outlays to expand into new markets? a. Staff model b. Group model c. Network model d. IPA model

Who employs the physicians in the group practice model? a. The HMO b. The group practice c. The IPA d. The PPO

A network model HMO: a. employs its own network of physicians b. exclusively uses the services of an independent practice association c. owns a network of physicians and hospitals d. contracts with more than one group practices

Which model of HMO was specifically included in the HMO Act of 1973? a. Staff model b. Group model c. Network model d. IPA mode

Under which model is an HMO relieved of the burden to establish contracts with providers and monitor utilization? a. Staff model b. Group model c. Network model d. IPA model

Who is likely to bear the most financial risk under the IPA model? a. The IPA b. The providers c. The HMO d. The employers

Among HMOs, which model is predominant in the marketplace? a. Staff model b. Group model c. Network model d. IPA model

PPOs were created by ____ in response to HMOs' growing market share. a. physicians b. insurance companies c. hospitals d. independent contractors

PPOs differentiated themselves by offering _____ options to enrollees. a. point of service b. no out-of-pocket payment c. open-panel d. discount

A hybrid between an HMO and a PPO. a. Point-of-service plans b. Mixed model HMO c. IPA d. Exclusive provider plans

Which type of MCO has achieved the greatest success in member enrollment? a. HMOs b. PPOs c. POS plans d. Exclusive provider plans

How are employers coping with the rising cost of health insurance premiums? a. They are dropping health benefits in large numbers b. They are enrolling a greater number of their employees into HMOs c. They are shifting costs to their employees d. They are switching to high-deductible health plans in large numbers

Which legislation was mainly responsible for giving states the authority to enroll a large number of Medicaid recipients into managed care? a. Tax Equity and Fiscal Responsibility Act of 1982 b. Balanced Budget Act of 1997 c. HMO Act of 1973 d. Deficit Reduction Act of 2005

Which legislation was mainly responsible for the decline of Medicare enrollments in managed care after a rise in enrollments? a. Tax Equity and Fiscal Responsibility Act of 1982 b. Balanced Budget Act of 1997 c. Medicare Prescription Drug, Improvement, and Modernization Act of 2003 d. Deficit Reduction Act of 2005

The Newborns' and Mothers' Health Protection Act of 1996 prohibits a health plan to offer less than _____ of inpatient stay following a normal vaginal delivery. a. 24 hours b. 48 hours c. 3 days d. 4 days

The Newborns' and Mothers' Health Protection Act of 1996 prohibits a health plan to offer less than _____ hours of inpatient stay following a Caesarean section. a. 48 b. 72 c. 96 d. 120

Which of the following is not an example of consolidation? a. Building of new facilities b. Acquiring an existing facility c. Merging with an existing organization d. Alliances among existing organizations

Which of these organizations was specifically created to bring management expertise to physician group practices? a. Virtual organizations b. Physician-hospital organizations c. Provider-sponsored organizations d. Management services organizations

An organization ceases to exist as a separate entity and is absorbed into the purchasing corporation. a. Acquisition b. Merger c. Joint venture d. Alliance

Two organizations cease to exist, and a new corporation is formed. a. Acquisition b. Merger c. Joint venture d. Alliance

A new corporation created by two partnering organizations remains independent. a. Acquisition b. Merger c. Joint venture d. Alliance

A type of integration that does not involve any joint ownership of assets. a. Acquisition b. Merger c. Joint venture d. Alliance

What type of integration is represented by a chain of nursing homes? a. Vertical integration b. Network c. Horizontal integration d. Diversification

Regional health systems are often: a. horizontally integrated b. vertically integrated c. formed into virtual organizations d. formed into alliances

Antitrust legislation is intended to provide checks against: a. anticompetitive behavior b. fraud and abuse c. self-referral of patients d. payments for patient referrals

Under a payment arrangement in which physicians are paid a fixed salary and performance-based bonuses, risk is shifted from the MCO to the physicians.

By prescribing minimum medical loss ratios in health plans, the ACA will limit the percentage of premium revenue a health plan can use for administration, marketing, and profits.

The emergence of PPOs was triggered by competition between HMOs and commercial insurance companies.

All MCOs are now required to be accredited by the National Committee for Quality Assurance.

Utilization is better controlled under a closed-panel plan than under an open-panel plan.

Case management is mainly recommended for patients who need secondary and tertiary care more often than primary care.

Disease management is highly individualized.

One distinguishing feature of HMOs is that they use discounted fees as the primary method of paying providers.

A triple-option plan includes indemnity insurance as an option.

By law, an HMO is prohibited from having an exclusive contract with a group practice.

In the IPA model, the IPA rather than the HMO contracts with the physicians.

The majority of Medicaid beneficiaries and enrollees in Medicare Advantage plans receive health care services through HMOs.

The four main HMO models differ according to payment arrangements with physicians.

In the 1990s, managed care was widely credited for enabling small employers to offer health insurance coverage to their employees.

Research shows that quality of care has declined as managed care has continued to grow.

The objective of horizontal integration is to control the geographic distribution of a service.

Diversification is not achieved through horizontal integration.