Deck 12: Managed Care

Question 1

Which of the following is NOT an advantage of PHO plans?

A) Result in improved managed care and favorable practice patterns
B) Ability to track and use data to manage delivery
C) Formation of better relationships between hospital and medical staff
D) Ability to negotiate with managed care plans

Answer 1

Result in improved managed care and favorable practice patterns

Question 2

The American Medical Association (AMA) approved of prepaid group practices.

Answer 2

False

Question 3

Which of the following is NOT a basic characteristic of HMOs?

A) The members are involuntarily enrolled for a specified period.
B) The HMO provides services on a prepaid basis.
C) An HMO contracts with providers to deliver care to its patients.
D) The HMO assumes legal, financial, public, and professional accountability.

Answer 3

The members are involuntarily enrolled for a specified period.

Question 4

Which of the following is NOT true of staff model HMOs?

A) Employs providers to deliver care to enrollees at their facilities
B) Also referred to as open panel
C) Typically operate out of large, freestanding ambulatory centers in which they provide a wide range of patient services
D) Pays physicians on staff on a salary basis and may pay bonuses based on efficiency and productivity

Question 5

Which of the following is NOT an advantage of POS plans?

A) Increased freedom of choice
B) Access to outside clinicians
C) Low copays
D) Low deductibles

Question 6

When did the United States Supreme Court find the AMA and Medical Society of the District of Columbia guilty of restricting trade due to a violation of the Sherman Anti-Trust Act (1890)?

A) 1943
B) 1937
C) 1933
D) 1938

Question 7

Which of the following is a disadvantage for clinicians of staff model HMOs?

A) Input into management decisions
B) Limited income potential
C) More input into clinical practice decisions
D) Complete autonomy

Question 8

Who coined the term health maintenance organization (HMO) to describe prepaid group practices?

A) William Mulholland
B) Harrison Gray Otis
C) Dr. Paul Elwood
D) Dr. Sidney Garfield

Question 9

Match the term with the appropriate definition or description:
Managed care plans are heavily regulated by both federal and state governments.

Question 10

Match the term with the appropriate definition or description:
Empirical evidence supports the fears that HMOs uniformly deliver inferior quality of care.

Question 11

Throughout the history of managed care, the AMA has been an important stakeholder in lobbying for legislation that benefited physicians.

Question 12

When was the Group Health Association in Washington, D.C., for federal workers formed?

A) 1943
B) 1937
C) 1933
D) 1938

Question 13

Which of the following is a characteristic of a managed care plan

A) Focus is on individual services or episodes of illness.
B) Maximum income is dependent on high volumes of service.
C) There is little financial incentive for preventive, primary care.
D) Maximum income for providers is dependent on effective treatment, or low volumes, of service management.

Question 14

PPO patients can see a provider that is not preferred with no additional cost in copayments, coinsurance, and deductibles.

Question 15

Which of the following is an advantage for clinicians of staff model HMOs?

A) Limited monetary investment in the practice
B) Limited financial risk to providers because they are salaried and have regular working hours
C) Limited legal risk for its employees
D) All of the above

Question 16

Which of the following is one of many factors influencing people's anxiety about managed care?

A) Higher cost of insurance
B) Empirical evidence shows lower quality of care
C) The media coverage of negative outcomes
D) None of the above

Question 17

Match the term with the appropriate definition or description:
Empirical evidence supports expectations that HMOs would increase overall quality of care

Question 18

Which of the following is NOT true about PPOs?

A) Contracts with independent clinicians to provide care services at a discount
B) Identifies physicians, hospitals, and other providers, as preferred
C) Gives patients no financial incentive to use the preferred providers
D) Reimburses providers on a fee-for-service discounted basis, so the provider is not at financial risk

Question 19

Employers are limiting plan choice more often, which means that dissatisfied consumers frequently cannot move out of their health plan as easily.

Question 20

Who provided medical care to construction workers in the desert on the Los Angeles aqueduct in exchange for a prepaid, per capita amount deducted from their paychecks?

A) William Mulholland
B) Harrison Gray Otis
C) Dr. Paul Elwood
D) Dr. Sidney Garfield

Question 21

Which of the following is a characteristic of a fee-for-service plan

A) Focus is on managed health over time.
B) Maximum income is dependent on high volumes of service.
C) There is an emphasis on preventive/primary care.
D) Maximum income for providers is dependent on effective treatment, or low volumes, of service management.
Completion
Complete each statement.

Question 22

Physicians had a __view of HMO impact on the knowledge that patients obtain about their overall care and the frequency of delivery of preventive care services.

Question 23

Match the term with the appropriate definition or description:
Usually a primary care physician (PCP), who must authorize specialty care before any is rendered

A)closed panel
B)gatekeeper
C)group model HMO
D)HMO Act of 1973
E)independent practice association (IPA)
F)integrated delivery system (IDS)
G)Kaiser Permanente
H)managed care
I)managed indemnity plans
J)network model HMO
K)open panel
L)per member per month (PMPM)
M)HMO
N)staff model HMO
O)capitation
P)physician hospital organization (PHO)
Q)copayment

Question 24

Match the term with the appropriate definition or description:
System of health care delivery that monitors the cost, quality, and access to health care

A)closed panel
B)gatekeeper
C)group model HMO
D)HMO Act of 1973
E)independent practice association (IPA)
F)integrated delivery system (IDS)
G)Kaiser Permanente
H)managed care
I)managed indemnity plans
J)network model HMO
K)open panel
L)per member per month (PMPM)
M)HMO
N)staff model HMO
O)capitation
P)physician hospital organization (PHO)
Q)copayment

Question 25

With its influence, the AMA managed to scale back the HMO Act of 1973 to only an "______."

Question 26

President Richard Nixon, in a nationwide television address in the early 1970s, proposed to "______" the United States with HMOs by the end of the decade.

Question 27

The __model HMO contracts with an established medical group for the provision of health care services instead of individual clinicians.

Question 28

____is the tendency to attract members to the managed care plan who are sicker than the general population.

Question 29

Managed care plans prefer to insure __rather than __because of the healthy worker effect, which holds that a person must have a certain level of health if he or she is able to remain successfully employed.

Question 30

Match the term with the appropriate definition or description:
A managed care plan that contracts with physicians and other primary care clinicians on an exclusive basis for services

A)closed panel
B)gatekeeper
C)group model HMO
D)HMO Act of 1973
E)independent practice association (IPA)
F)integrated delivery system (IDS)
G)Kaiser Permanente
H)managed care
I)managed indemnity plans
J)network model HMO
K)open panel
L)per member per month (PMPM)
M)HMO
N)staff model HMO
O)capitation
P)physician hospital organization (PHO)
Q)copayment

Question 31

Physicians perceived HMOs had a __effect on the physician-patient relationship by limiting time spent with patients, reducing freedom to make clinical decisions, and deterring the ordering of expensive tests/procedures.

Question 32

The __of 1973 provided grants and loans for the establishment of HMOs.

Question 33

Match the term with the appropriate definition or description:
A hybrid form of HMO, which allows physicians to provide services in their solo offices and bill the organization

A)closed panel
B)gatekeeper
C)group model HMO
D)HMO Act of 1973
E)independent practice association (IPA)
F)integrated delivery system (IDS)
G)Kaiser Permanente
H)managed care
I)managed indemnity plans
J)network model HMO
K)open panel
L)per member per month (PMPM)
M)HMO
N)staff model HMO
O)capitation
P)physician hospital organization (PHO)
Q)copayment

Question 34

What usually makes managed indemnity different is ______, which means that some of the care members receive is subject to preapproval.

Question 35

Match the term with the appropriate definition or description:
A managed care plan that contracts with private clinicians to deliver care; however, the clinicians may see other patients not in the plan

A)closed panel
B)gatekeeper
C)group model HMO
D)HMO Act of 1973
E)independent practice association (IPA)
F)integrated delivery system (IDS)
G)Kaiser Permanente
H)managed care
I)managed indemnity plans
J)network model HMO
K)open panel
L)per member per month (PMPM)
M)HMO
N)staff model HMO
O)capitation
P)physician hospital organization (PHO)
Q)copayment

Question 36

Match the term with the appropriate definition or description:
Provided grants and loans for the establishment of HMOs

A)closed panel
B)gatekeeper
C)group model HMO
D)HMO Act of 1973
E)independent practice association (IPA)
F)integrated delivery system (IDS)
G)Kaiser Permanente
H)managed care
I)managed indemnity plans
J)network model HMO
K)open panel
L)per member per month (PMPM)
M)HMO
N)staff model HMO
O)capitation
P)physician hospital organization (PHO)
Q)copayment

Question 37

Match the term with the appropriate definition or description:
The health insurance company has the highest HMO enrollment in the United States.

A)closed panel
B)gatekeeper
C)group model HMO
D)HMO Act of 1973
E)independent practice association (IPA)
F)integrated delivery system (IDS)
G)Kaiser Permanente
H)managed care
I)managed indemnity plans
J)network model HMO
K)open panel
L)per member per month (PMPM)
M)HMO
N)staff model HMO
O)capitation
P)physician hospital organization (PHO)
Q)copayment

Question 38

A __model HMO contracts with multiple physician groups to deliver health care to members.

Question 39

Which of the following is a disadvantage of POS plans?

A) More costly structure than HMOs
B) High copays and deductibles for non-network care
C) Referrals for specialists may be difficult to obtain
D) All of the above

Question 40

It is not advantageous for a managed care company to provide coverage for sick enrollees from a ______/loss standpoint.

Question 41

Match the term with the appropriate definition or description:
Contracts with multiple physician groups to deliver health care to members

A)closed panel
B)gatekeeper
C)group model HMO
D)HMO Act of 1973
E)independent practice association (IPA)
F)integrated delivery system (IDS)
G)Kaiser Permanente
H)managed care
I)managed indemnity plans
J)network model HMO
K)open panel
L)per member per month (PMPM)
M)HMO
N)staff model HMO
O)capitation
P)physician hospital organization (PHO)
Q)copayment

Question 42

Match the term with the appropriate definition or description:
An organized system of health care providers that spans a broad range of health care services by using vertical integration to contract with a variety of clinicians and health plans

A)closed panel
B)gatekeeper
C)group model HMO
D)HMO Act of 1973
E)independent practice association (IPA)
F)integrated delivery system (IDS)
G)Kaiser Permanente
H)managed care
I)managed indemnity plans
J)network model HMO
K)open panel
L)per member per month (PMPM)
M)HMO
N)staff model HMO
O)capitation
P)physician hospital organization (PHO)
Q)copayment

Question 43

Match the term with the appropriate definition or description:
A common capitation measure

A)closed panel
B)gatekeeper
C)group model HMO
D)HMO Act of 1973
E)independent practice association (IPA)
F)integrated delivery system (IDS)
G)Kaiser Permanente
H)managed care
I)managed indemnity plans
J)network model HMO
K)open panel
L)per member per month (PMPM)
M)HMO
N)staff model HMO
O)capitation
P)physician hospital organization (PHO)
Q)copayment

Question 44

Match the term with the appropriate definition or description:
Employs providers to deliver care to enrollees at their facilities

A)closed panel
B)gatekeeper
C)group model HMO
D)HMO Act of 1973
E)independent practice association (IPA)
F)integrated delivery system (IDS)
G)Kaiser Permanente
H)managed care
I)managed indemnity plans
J)network model HMO
K)open panel
L)per member per month (PMPM)
M)HMO
N)staff model HMO
O)capitation
P)physician hospital organization (PHO)
Q)copayment

Question 45

Match the term with the appropriate definition or description:
A set amount of money paid per enrollee for a predetermined set of benefits to be rendered if medically necessary

A)closed panel
B)gatekeeper
C)group model HMO
D)HMO Act of 1973
E)independent practice association (IPA)
F)integrated delivery system (IDS)
G)Kaiser Permanente
H)managed care
I)managed indemnity plans
J)network model HMO
K)open panel
L)per member per month (PMPM)
M)HMO
N)staff model HMO
O)capitation
P)physician hospital organization (PHO)
Q)copayment

Question 46

Match the term with the appropriate definition or description:
An organization that provides a wide range of comprehensive health care services for a specified group of subscribers for a fixed, prenegotiated, periodic rate, normally a PMPM capitation rate

A)closed panel
B)gatekeeper
C)group model HMO
D)HMO Act of 1973
E)independent practice association (IPA)
F)integrated delivery system (IDS)
G)Kaiser Permanente
H)managed care
I)managed indemnity plans
J)network model HMO
K)open panel
L)per member per month (PMPM)
M)HMO
N)staff model HMO
O)capitation
P)physician hospital organization (PHO)
Q)copayment

Question 47

Match the term with the appropriate definition or description:
A system that bonds clinicians and hospitals together to form an IDS

A)closed panel
B)gatekeeper
C)group model HMO
D)HMO Act of 1973
E)independent practice association (IPA)
F)integrated delivery system (IDS)
G)Kaiser Permanente
H)managed care
I)managed indemnity plans
J)network model HMO
K)open panel
L)per member per month (PMPM)
M)HMO
N)staff model HMO
O)capitation
P)physician hospital organization (PHO)
Q)copayment

Question 48

Match the term with the appropriate definition or description:
Portion of a claim or medical expense that a member must pay out-of-pocket at the time of treatment; usually a fixed amount

A)closed panel
B)gatekeeper
C)group model HMO
D)HMO Act of 1973
E)independent practice association (IPA)
F)integrated delivery system (IDS)
G)Kaiser Permanente
H)managed care
I)managed indemnity plans
J)network model HMO
K)open panel
L)per member per month (PMPM)
M)HMO
N)staff model HMO
O)capitation
P)physician hospital organization (PHO)
Q)copayment

Question 49

Match the term with the appropriate definition or description:
Contracts with an established medical group for the provision of health care services, instead of individual clinicians.

A)closed panel
B)gatekeeper
C)group model HMO
D)HMO Act of 1973
E)independent practice association (IPA)
F)integrated delivery system (IDS)
G)Kaiser Permanente
H)managed care
I)managed indemnity plans
J)network model HMO
K)open panel
L)per member per month (PMPM)
M)HMO
N)staff model HMO
O)capitation
P)physician hospital organization (PHO)
Q)copayment

Question 50

Match the term with the appropriate definition or description:
Some of the care members receive is subject to preapproval

A)closed panel
B)gatekeeper
C)group model HMO
D)HMO Act of 1973
E)independent practice association (IPA)
F)integrated delivery system (IDS)
G)Kaiser Permanente
H)managed care
I)managed indemnity plans
J)network model HMO
K)open panel
L)per member per month (PMPM)
M)HMO
N)staff model HMO
O)capitation
P)physician hospital organization (PHO)
Q)copayment