HSA EXAM 2 QUESTIONS AND ANSWERS
moral hazard - Answers :-consumer behavior that leads to a higher utilization of health
care services when the services are covered by insurance
-wastes resources and adds to the rising cost of health care
Primary purpose of insurance - Answers :-protects against risk of a substantial financial
loss
ACA Mandates- insurance - Answers :-employers with 100+ full time workers must
cover at least 70% of workers starting in 2015 and 95% by 2016
- made it illegal to deny health insurance to people w preexisting conditions and
required young adults under 26 to be covered under parents plan
- residents of US are required to have minimum essential coverage
Community oriented primary care - Answers :-domain of primary care that incorporates
elements of primary care delivery and adds a population based approach to identifying
and addressing community health problems
-main challenge- how to bring together individual needs in the larger context of
community health needs
-two major barriers include workforce shortages and financial incentives
Medical Home model - Answers :-recommended as an improved fundamental change in
the provision and financing of primary care
-advocates practice of patient-centered care based on partnership between pt and the
provider and incorporates principles of chronic care model, which is based on premise
that chronic conditions are best managed with multi disciplinary practice-based teams
- has been found to improve health outcomes and satisfaction, reduce med errors, and
add value by producing cost savings without compromising outcomes
prospective reimbursement - Answers :-uses preestablished criteria to determine in
advanced the amount of reimbursement
diagnosis related groups - Answers :type of prospective reimbursement used to pay for
hospital inpatient services
-sets bundle price according to diagnosis at time of admission
-has forced hospitals to control their costs and minimize inpatient stay
Ambulatory payment classifications - Answers :type of prospective reimbursement that
divides outpatient services into procedural groups and reimbursement rates are
associated with each group
Resource utilization groups - Answers :type of prospective reimbursement that has
categories used for determining overall severity of health condition requiring medical
intervention
, Home health resource groups - Answers :type of prospective reimbursement that has
fixed, predetermined rates for each 60 day episode of care regardless of specific
services delivered
- all services bundled under one payment made on a per patient basis
Fee for service - Answers :payment based on assumption that services are provided in
set of identifiable and individually distinct unit of services
- disfavored due to cost escalations
Bundled payments - Answers :number of related services are included in one price
Resource-based relative value scale - Answers :reimbursement method that reimburses
physicians according to a relative value assigned to each service
-based on time, skill, and intensity it takes to provide service
Capitation - Answers :provider is paid a set monthly fee per enrollee regardless of
whether enrollee sees provider or not
impact of managed care on cost - Answers :- primary responsibility of cost containment
falls on private sector- tries to contain costs through expansion of managed care
Impact of managed care on access - Answers :-screenings and favorable ratings of
physicians more likely for areas with greater HMO market share
-in MA plans, better access to primary care and lowered risk of preventable
hospitalizations
- in Medicaid managed care- increased use of ED and difficulty in seeing specialists
Impact of managed care on quality of care - Answers :-quality has improved over time
-under capitation ,physician takes full responsibility for pt's overall care
- HMO and non HMO plans provide equal quality of care as measured by range of
conditions, diseases, and interventions
integrated delivery systems - Answers :several orgs under ownership or contractual
arrangements that provide an array of health care services to large communities
-complex and difficult to manage
-reduce duplication of services and share resources to contain cost
ACOs - Answers :Accountable care organizations
-integrated group of providers who work together to deliver coordinated care and take
responsibility for quality and efficiency of services
-ACA authorized formation of these to serve Medicare beneficiaries enrolled in fee for
service program
-heavily criticized
moral hazard - Answers :-consumer behavior that leads to a higher utilization of health
care services when the services are covered by insurance
-wastes resources and adds to the rising cost of health care
Primary purpose of insurance - Answers :-protects against risk of a substantial financial
loss
ACA Mandates- insurance - Answers :-employers with 100+ full time workers must
cover at least 70% of workers starting in 2015 and 95% by 2016
- made it illegal to deny health insurance to people w preexisting conditions and
required young adults under 26 to be covered under parents plan
- residents of US are required to have minimum essential coverage
Community oriented primary care - Answers :-domain of primary care that incorporates
elements of primary care delivery and adds a population based approach to identifying
and addressing community health problems
-main challenge- how to bring together individual needs in the larger context of
community health needs
-two major barriers include workforce shortages and financial incentives
Medical Home model - Answers :-recommended as an improved fundamental change in
the provision and financing of primary care
-advocates practice of patient-centered care based on partnership between pt and the
provider and incorporates principles of chronic care model, which is based on premise
that chronic conditions are best managed with multi disciplinary practice-based teams
- has been found to improve health outcomes and satisfaction, reduce med errors, and
add value by producing cost savings without compromising outcomes
prospective reimbursement - Answers :-uses preestablished criteria to determine in
advanced the amount of reimbursement
diagnosis related groups - Answers :type of prospective reimbursement used to pay for
hospital inpatient services
-sets bundle price according to diagnosis at time of admission
-has forced hospitals to control their costs and minimize inpatient stay
Ambulatory payment classifications - Answers :type of prospective reimbursement that
divides outpatient services into procedural groups and reimbursement rates are
associated with each group
Resource utilization groups - Answers :type of prospective reimbursement that has
categories used for determining overall severity of health condition requiring medical
intervention
, Home health resource groups - Answers :type of prospective reimbursement that has
fixed, predetermined rates for each 60 day episode of care regardless of specific
services delivered
- all services bundled under one payment made on a per patient basis
Fee for service - Answers :payment based on assumption that services are provided in
set of identifiable and individually distinct unit of services
- disfavored due to cost escalations
Bundled payments - Answers :number of related services are included in one price
Resource-based relative value scale - Answers :reimbursement method that reimburses
physicians according to a relative value assigned to each service
-based on time, skill, and intensity it takes to provide service
Capitation - Answers :provider is paid a set monthly fee per enrollee regardless of
whether enrollee sees provider or not
impact of managed care on cost - Answers :- primary responsibility of cost containment
falls on private sector- tries to contain costs through expansion of managed care
Impact of managed care on access - Answers :-screenings and favorable ratings of
physicians more likely for areas with greater HMO market share
-in MA plans, better access to primary care and lowered risk of preventable
hospitalizations
- in Medicaid managed care- increased use of ED and difficulty in seeing specialists
Impact of managed care on quality of care - Answers :-quality has improved over time
-under capitation ,physician takes full responsibility for pt's overall care
- HMO and non HMO plans provide equal quality of care as measured by range of
conditions, diseases, and interventions
integrated delivery systems - Answers :several orgs under ownership or contractual
arrangements that provide an array of health care services to large communities
-complex and difficult to manage
-reduce duplication of services and share resources to contain cost
ACOs - Answers :Accountable care organizations
-integrated group of providers who work together to deliver coordinated care and take
responsibility for quality and efficiency of services
-ACA authorized formation of these to serve Medicare beneficiaries enrolled in fee for
service program
-heavily criticized
