Chapter 2: Access to Healthcare: Rights and Responsibilities.

Question 1

Which federal healthcare program is NOT run by the federal government?

Answer 1

All of the programs mentioned in the chapter (Medicare, Medicaid, CHIP, TRICARE, Veterans Administration healthcare, Indian Health Service, and U.S. Public Health Service) are run by the federal government.

Question 2

The first significant healthcare issue decided by the U.S. Supreme Court was:
A) Dent v. West Virginia (1889)
B) Tarasoff v. Regents of University of California
C) Wickline v. State of California
D) NFIB v. Sebelius

Answer 2

A) Dent v. West Virginia (1889) - A case about physician licensure that established the state’s right to regulate medical practice.

Question 3

Which act was the first federal legislation concerning healthcare?
A) The Meat Inspection Act of 1906
B) The Sheppard-Towner Act
C) The Vaccine Act of 1813
D) The Hill-Burton Act of 1946

Answer 3

C) The Vaccine Act of 1813 - It provided for the appointment of a federal agent to preserve and distribute smallpox vaccine.

Question 4

What was the major issue in King v. Burwell (2015)?
A) Whether the individual mandate was constitutional
B) Whether tax credits were available in states with federally-established exchanges
C) Whether Medicaid expansion could be mandatory
D) Whether the ACA violated religious freedoms

Answer 4

B) Whether tax credits were available in states with federally-established exchanges - The Court ruled that subsidies were available regardless of whether the state or federal government established the exchange.

Question 5

The “three-layered cake” proposal that eventually became Medicare and Medicaid included:
A) Hospital insurance for elderly, physician coverage, and assistance to states for the poor
B) Veterans coverage, elderly coverage, and assistance for disabled
C) Children’s coverage, maternal care, and elderly coverage
D) Preventive care, hospital coverage, and catastrophic coverage

Answer 5

A) Hospital insurance for elderly, physician coverage, and assistance to states for the poor - These became Medicare Part A, Medicare Part B, and Medicaid respectively.

Question 6

Which of the following was NOT a provision of the Hill-Burton Act?
A) Federal financing for hospital construction
B) Uncompensated care obligation
C) Community service obligation
D) Requirements for physician staffing

Answer 6

D) Requirements for physician staffing - The Hill-Burton Act focused on hospital construction and providing care to the poor, not physician staffing requirements.

Question 7

Under common law, which statement is true regarding a hospital’s duty to treat patients?
A) Hospitals must treat all patients regardless of ability to pay
B) Hospitals have no duty to treat any specific individual except in emergencies
C) Hospitals must admit all patients with a physician’s order
D) Only government hospitals have a duty to treat patients

Answer 7

B) Hospitals have no duty to treat any specific individual except in emergencies - This was the black-letter law established in cases like Hill v. Ohio County.

Question 8

The term “adverse selection” in health insurance refers to:
A) Insurance companies denying coverage based on preexisting conditions
B) High-risk individuals choosing more generous insurance plans while healthy people go uninsured
C) Government selecting which insurers can participate in exchanges
D) Patients selecting providers outside their network

Answer 8

B) High-risk individuals choosing more generous insurance plans while healthy people go uninsured - This can lead to a “death spiral” of increasing premiums.

Question 9

Which statement about Medicaid is correct?
A) It is entirely funded by the federal government
B) It is administered identically in all states
C) Federal funds cover at least 50% of a state’s Medicaid budget
D) All physicians must accept Medicaid patients

Answer 9

C) Federal funds cover at least 50% of a state’s Medicaid budget - The amount varies based on a formula that includes average per capita income for each state.

Question 10

The individual mandate in the ACA:
A) Required all Americans to purchase health insurance or pay a penalty
B) Required only employed individuals to have health insurance
C) Required states to expand Medicaid
D) Required employers to provide health insurance

Answer 10

A) Required all Americans to purchase health insurance or pay a penalty - Though there were some exemptions, and the tax penalty was later reduced to $0 through the 2017 tax reform bill.

Question 11

Civil commitment of mentally ill persons requires:
A) Family consent only
B) Only a physician’s determination
C) Either danger to self or others
D) A court order and nothing else

Answer 11

C) Either danger to self or others - Patients cannot be involuntarily committed unless they present a danger to themselves or others.

Question 12

The medical loss ratio (MLR) represents:
A) The percentage of premium dollars paid for medical care and quality improvement
B) The percentage of patients who die while under medical care
C) The percentage of medical procedures that result in complications
D) The percentage of hospital admissions that are deemed unnecessary

Answer 12

A) The percentage of premium dollars paid for medical care and quality improvement.

Question 13

Healthcare providers’ obligations under the Emergency Medical Treatment and Labor Act (EMTALA) include:
A) Providing free care to all emergency patients
B) Stabilizing emergency conditions regardless of ability to pay
C) Admitting all emergency patients as inpatients
D) Transferring all uninsured patients to public hospitals

Answer 13

B) Stabilizing emergency conditions regardless of ability to pay - EMTALA was passed in 1986 to prevent “patient dumping.”

Question 14

Under the doctrine of parens patriae, the state has the power to:
A) Regulate all aspects of healthcare delivery
B) Provide needed care to mentally ill persons who present a danger to themselves
C) Determine which physicians can practice medicine
D) Set rates for healthcare services

Answer 14

B) Provide needed care to mentally ill persons who present a danger to themselves - The state acts as the “father of the country” to protect those who cannot protect themselves.

Question 15

In the O’Connor v. Donaldson case, the Supreme Court ruled that:
A) States can confine mentally ill persons indefinitely regardless of dangerousness
B) Mental illness alone cannot justify involuntary confinement if the person is not dangerous
C) All mental health facilities must provide comprehensive treatment
D) Mentally ill patients have no right to refuse medication

Answer 15

B) Mental illness alone cannot justify involuntary confinement if the person is not dangerous - The Court established that non-dangerous individuals cannot be confined if they can live safely in freedom.

Question 16

The “death spiral” in health insurance markets refers to:
A) Increasing mortality rates due to poor coverage
B) A cycle where premiums rise, healthy people drop coverage, risk pool worsens, and premiums rise further
C) Insurance companies going bankrupt
D) Government takeover of failing insurance markets

Answer 16

B) A cycle where premiums rise, healthy people drop coverage, risk pool worsens, and premiums rise further - This phenomenon can eventually cause a market to collapse.

Question 17

The ruling in NFIB v. Sebelius (2012) determined that:
A) The individual mandate was constitutional under Congress’s taxing authority
B) The ACA was unconstitutional in its entirety
C) States must expand their Medicaid programs
D) The federal government could not establish health insurance exchanges

Answer 17

A) The individual mandate was constitutional under Congress’s taxing authority - The Court ruled it was not valid under the Commerce Clause but was allowable as a tax.

Question 18

Which statement about Hill-Burton Act obligations is correct?
A) All hospitals must provide some free care regardless of funding
B) The obligation to provide uncompensated care lasted indefinitely
C) Original recipients had a 20-year uncompensated care obligation
D) All obligations ended when Medicare was established

Answer 18

C) Original recipients had a 20-year uncompensated care obligation - The 1974 National Health Planning and Resource Development Act changed this to make the obligation indefinite for new recipients.

Question 19

The first Blue Cross plan was created in:
A) 1913 at the Los Angeles Aqueduct project
B) 1929 at Baylor University Hospital for teachers
C) 1946 under the Hill-Burton Act
D) 1965 with the advent of Medicare

Answer 19

B) 1929 at Baylor University Hospital for teachers - Justin Ford Kimball offered a way for 1,300 school teachers in Dallas to finance hospital care through small monthly payments.

Question 20

The Patient Protection and Affordable Care Act (ACA) was passed in:
A) 2008
B) 2009
C) 2010
D) 2012

Answer 20

C) 2010 - It was signed into law by President Obama in March 2010.

Question 21

Managed care plans attempt to reduce costs through all of the following EXCEPT:
A) Economic incentives
B) Reviews of medical necessity
C) Selective contracting with providers
D) Requiring all services to be provided at hospitals

Answer 21

D) Requiring all services to be provided at hospitals - Managed care plans typically try to move care to less expensive settings when appropriate.

Question 22

Which of the following groups was exempt from the ACA’s individual mandate?
A) All individuals over age 50
B) Individuals with incomes below 400% of the poverty line
C) Undocumented immigrants
D) All self-employed individuals

Answer 22

C) Undocumented immigrants - Non-citizens and undocumented immigrants were among those exempt from the mandate.

Question 23

Under the prospective payment system (PPS) for Medicare:
A) Hospitals are paid based on actual costs incurred
B) Hospitals are paid a predetermined amount based on diagnosis-related groups
C) Patients pay hospitals directly and are reimbursed by Medicare
D) Physicians determine payment rates for hospital services

Answer 23

B) Hospitals are paid a predetermined amount based on diagnosis-related groups - This system replaced cost-based reimbursement in the early 1980s.

Question 24

For a patient to be involuntarily committed for mental health treatment, most states require:
A) Just a physician’s recommendation
B) Evidence of mental illness and danger to self or others
C) Financial inability to pay for voluntary treatment
D) A criminal conviction

Answer 24

B) Evidence of mental illness and danger to self or others - Many states also require evidence of a timely overt act or threat of violence.

Question 25

Which of these is NOT required information collected during hospital registration? A) Demographics and contact information B) Insurance coverage C) Patient's political affiliation D) Religious affiliation (if disclosed)

Answer 25

C) Patient's political affiliation - This is not standard information collected during registration.

Question 26

What court case established that Medicare did not need to pay for custodial care when skilled nursing facilities were unavailable? A) Monmouth Medical Center v. State B) Monmouth Medical Center v. Harris C) City of Revere v. Massachusetts General Hospital D) St. Joseph's Hospital v. Maricopa County

Answer 26

B) Monmouth Medical Center v. Harris - The court upheld the government's right to deny Medicare reimbursement for custodial care even when alternatives were unavailable.

Question 27

The principles established in the Tarasoff case relate to: A) A hospital's duty to admit all patients B) A healthcare provider's duty to warn potential victims of dangerous patients C) A hospital's duty to provide emergency care D) A physician's duty to obtain informed consent

Answer 27

B) A healthcare provider's duty to warn potential victims of dangerous patients - This case established that mental health professionals have a duty to protect potential victims from dangerous patients.

Question 28

A hospital that discharges a patient who still needs care without making appropriate arrangements could be liable for: A) Battery B) Fraudulent billing C) Abandonment D) Breach of contract

Answer 28

C) Abandonment - This requires a physician's discharge order to be reasonable under the circumstances.

Question 29

Which of these was a significant criticism of the pre-ACA healthcare system according to the chapter? A) Overemphasis on primary care B) Too much focus on preventive medicine C) Too much emphasis on hospital treatment, not enough on primary care D) Excessive regulation of healthcare providers

Answer 29

C) Too much emphasis on hospital treatment, not enough on primary care - The system was "seriously out of balance" with virtually no emphasis on wellness and prevention.

Question 30

Which constitutional amendments have been interpreted to require governments to provide convicted prisoners with adequate medical treatment? A) First and Fourth Amendments B) Fifth and Fourteenth Amendments C) Eighth Amendment D) Tenth Amendment

Answer 30

C) Eighth Amendment - Its prohibition of cruel and unusual punishment has been interpreted to require adequate medical treatment for prisoners.

Question 31

The term "Medicare Administrative Contractors" (MACs) refers to: A) Federal employees who administer Medicare B) Private companies that process Medicare claims on behalf of the government C) Hospital employees who handle Medicare billing D) Physicians who accept Medicare patients

Answer 31

B) Private companies that process Medicare claims on behalf of the government - These were originally known as Part A Fiscal Intermediaries and Part B Carriers.

Question 32

Which of the following is NOT a function of Peer Review Organizations (PROs)? A) Determining whether hospital services are reasonable and medically necessary B) Setting payment rates for Medicare C) Evaluating whether services meet professional standards D) Determining if services could be provided more economically elsewhere

Answer 32

B) Setting payment rates for Medicare - PROs review quality and appropriateness of care but do not set payment rates.

Question 33

If a mentally ill patient is determined to be competent, they generally: A) Cannot refuse any treatment recommended by physicians B) Can refuse treatment unless they are a danger to themselves or others C) Must be released immediately regardless of condition D) Must have all decisions made by a court-appointed guardian

Answer 33

B) Can refuse treatment unless they are a danger to themselves or others - Competent patients have the right to consent or refuse care unless safety requires intervention.

Question 34

The problem of "medical identity theft" involves: A) Physicians practicing without proper credentials B) Stealing prescription pads to obtain medications C) Registering with another individual's insurance information or identifiers D) Taking medical equipment from hospitals

Answer 34

C) Registering with another individual's insurance information or identifiers - This can lead to financial losses and incorrect information in medical records.

Question 35

The ACA's "guaranteed issue" provision means that: A) Insurance companies must accept every employer and individual who applies B) Everyone is guaranteed a job with health benefits C) The government guarantees payment for all healthcare services D) Insurance coverage is guaranteed to remain unchanged

Answer 35

A) Insurance companies must accept every employer and individual who applies - They cannot deny coverage based on preexisting conditions.

Question 36

The "Harry and Louise" television ad campaign was: A) A government campaign promoting the ACA B) An insurance industry campaign opposing Clinton's healthcare reform C) A campaign encouraging preventive healthcare D) A public service announcement about Medicare enrollment

Answer 36

B) An insurance industry campaign opposing Clinton's healthcare reform - Ironically, these characters later returned to support healthcare reform during the Obama administration.

Question 37

How have the patterns of healthcare access in the US changed over time, and what factors have most significantly influenced these changes?

Answer 37

US healthcare access evolved from minimal government involvement to significant participation through: (1) Hill-Burton Act (1946) funding hospital construction; (2) Medicare/Medicaid (1965) covering elderly/poor; (3) Managed care (1970s-90s) attempting cost control; (4) ACA (2010) expanding coverage. Key influencing factors: political ideologies, economic considerations, provider interests, insurance industry leverage, and evolving social attitudes about healthcare as a right vs. privilege.

Question 38

Compare and contrast the legal principles governing involuntary commitment of psychiatric patients with those protecting general medical patients.

Answer 38

Psychiatric patients: (1) Require danger to self/others for commitment; (2) Need substantive and procedural due process; (3) Competent patients can refuse treatment unless dangerous; (4) Constitutional rights to adequate treatment, safe conditions, and freedom from unnecessary restraint. General patients: (1) Broader autonomy rights; (2) Can refuse treatment except in emergencies; (3) Discharge generally at patient's discretion. Both share informed consent rights, but psychiatric patients' rights can be limited more easily when safety concerns exist.

Question 39

Analyze how the ACA attempted to balance stakeholder interests and whether it achieved an appropriate equilibrium.

Answer 39

ACA balanced interests through: (1) Patients: coverage expansion, preexisting condition protections; (2) Providers: larger insured population; (3) Insurers: individual mandate for broader risk pools but increased regulation; (4) Government: Medicaid expansion with state flexibility. Balance was imperfect: industry secured significant compromises, mandate was politically contentious, complexity undermined public understanding, and millions remained uninsured. The political compromises necessary for passage created implementation challenges that continue to threaten the law's stability.

Question 40

Explain how the "death spiral" concept influenced the Supreme Court's reasoning in King v. Burwell.

Answer 40

In King v. Burwell, the Court recognized that without subsidies in federal exchanges: (1) Insurance would be unaffordable for many; (2) Individuals would be exempt from the mandate due to cost; (3) Only high-risk individuals would purchase coverage; (4) Premiums would rise; (5) More healthy people would exit; (6) Markets would collapse into "death spirals." Rather than strictly interpreting "Exchange established by the State," the Court prioritized the ACA's structural integrity and purpose of expanding functional insurance markets, concluding Congress couldn't have intended to design a system destined to fail.

Question 41

How do courts balance individual liberty and public safety in cases involving involuntary treatment of psychiatric patients?

Answer 41

Courts balance these interests by requiring: (1) Evidence of dangerousness, often through overt acts; (2) Professional determination that treatment is necessary; (3) Exploration of less restrictive alternatives; (4) Regular treatment review; (5) Procedural due process for longer commitments; (6) Presumption that mental illness doesn't automatically equal incompetence; (7) Treatment consistent with professional standards. This framework protects liberty when possible while permitting intervention when necessary for safety.

Question 42

Analyze the Supreme Court's reasoning in NFIB v. Sebelius regarding the individual mandate.

Answer 42

In NFIB v. Sebelius, the Court held: (1) The mandate exceeded Commerce Clause authority by regulating inactivity (not purchasing insurance) rather than economic activity; (2) However, the "shared responsibility payment" functioned as a tax: it generated revenue, was collected by IRS, lacked criminal penalties; (3) Therefore, the mandate was constitutional under Congress's taxing power; (4) The Medicaid expansion couldn't be coerced through threatening existing funding. This preserved the ACA while limiting Commerce Clause reach and respecting state sovereignty.

Question 43

How did the shift from cost-based reimbursement to prospective payment affect healthcare delivery incentives?

Answer 43

The shift created fundamental incentive changes: FROM: (1) More services = more payment; (2) Longer stays = more revenue; (3) No incentive for efficiency; TO: (1) Treating patients with fewer resources increases margins; (2) Shorter stays maximize profitability; (3) Moving care to outpatient settings when possible; (4) Focus on coding optimization to maximize reimbursement. This transformation represented government's first serious attempt to control Medicare costs after years of unconstrained growth, fundamentally changing provider behavior through financial incentives.

Question 44

How did Hill-Burton obligations evolve into modern community benefit requirements?

Answer 44

Evolution: (1) Hill-Burton initially required 20-year uncompensated care and community service obligations; (2) Poor enforcement led to litigation and stronger regulations; (3) 1974 law made obligations indefinite for new recipients; (4) Principles expanded to tax-exempt hospitals through IRS community benefit standard; (5) ACA formalized requirements through Section 501(r) including needs assessments and financial assistance policies. The progression represents a shift from specific contractual obligations to broader social responsibilities expected from healthcare institutions receiving public support through tax exemptions.

Question 45

Compare health policy reform approaches by Presidents Nixon, Clinton, and Obama.

Answer 45

Nixon (1970s): Proposed comprehensive national insurance with employer mandates. Failed due to Watergate and partisan politics despite Republican origin. Clinton (1993-94): Proposed "managed competition" through regional health alliances. Failed due to complexity, insurance industry opposition, and poor political execution. Obama (2009-10): Built on existing system with individual mandate and insurance reforms. Succeeded due to Democratic control of Congress, lessons from Clinton's failure, and incremental approach rather than system replacement. Key success factors: political control, industry accommodation, implementation strategy, and public understanding.

Question 46

What's the relationship between healthcare rights in the US and distributive justice?

Answer 46

The US has prioritized individual responsibility over distributive justice in healthcare, creating unequal access based on employment, age, and income. * Evolution has been incremental: from minimal government involvement to public health measures to safety net programs (Medicare/Medicaid) to expanded coverage (CHIP/ACA). * This represents gradual movement toward greater distributive justice, though still lacking universal coverage. * The fundamental tension remains between viewing healthcare as a market commodity versus a right requiring fair distribution regardless of ability to pay.

Question 47

Compare prisoners' constitutional right to healthcare with the general population's legal healthcare rights.

Answer 47

Prisoners have constitutional right to adequate healthcare under Eighth Amendment, while general population has no constitutional healthcare right. This creates the paradox where incarcerated individuals have a legally protected right that free citizens don't. Key differences: (1) Prisoners' right stems from government's responsibility when restricting liberty; (2) General population has primarily statutory/regulatory protections (EMTALA, ACA, etc.); (3) Distinction exists between duty to provide care and duty to pay for care. This illustrates tension between negative rights (freedom from interference) and positive rights (entitlement to services) in US constitutional structure.

Question 48

Would Hill v. Ohio County have the same outcome under current healthcare laws?

Answer 48

Outcome would differ today primarily due to EMTALA (1986), which would require: 1) Medical screening examination for the pregnant woman 2) Stabilization if emergency existed or appropriate transfer 3) Process regardless of payment ability or physician preference The hospital's failure to have qualified personnel examine the patient would violate federal law. Modern standards for hospital responsibilities, including Joint Commission requirements, would expect protocols for obstetric emergencies even without specialized OB services. While the basic common law principle (no general duty to treat) remains, statutory obligations have significantly expanded hospital responsibilities since this 1971 case.

Question 49

Medical loss ratio

Answer 49

The percentage of premium dollars spent on medical care and quality improvement efforts. The ACA sets minimum requirements of 80-85% depending on market size.

Question 50

What constitutional amendment prohibits cruel and unusual punishment, and how does it relate to prisoner healthcare? A) Fifth Amendment B) Eighth Amendment C) Fourteenth Amendment D) Fourth Amendment

Answer 50

B) Eighth Amendment - It prohibits cruel and unusual punishment and has been interpreted to require governments to provide convicted prisoners with adequate medical treatment.

Question 51

Spreading risk

Answer 51

The goal of any insurer to spread risk over a large enough population that losses can be predicted with reasonable accuracy. The larger the insured population, the more accurately losses and premiums can be calculated.

Question 52

Adverse selection

Answer 52

Occurs when high-risk individuals choose more generous and expensive insurance plans, while healthier people go uninsured or choose plans with lower premiums. If allowed to continue, this would make insurance companies unprofitable and eventually put them out of business.

Question 53

Third-party payers

Answer 53

Managed care organizations, government programs, employee benefit plans, private insurance plans, and similar entities responsible for paying for health services.

Question 54

Parens patriae

Answer 54

The doctrine that the government is the ultimate guardian of all people who have a legal disability, such as minors and the mentally ill. Literally means "father of the country."

Question 55

NFIB v. Sebelius (2012)

Answer 55

Supreme Court case that upheld the ACA's individual mandate as a constitutional exercise of Congress's taxing power (rather than under the Commerce Clause) and made Medicaid expansion optional for states rather than mandatory.

Question 56

King v. Burwell (2015)

Answer 56

Supreme Court case that upheld the availability of tax credits (subsidies) on federally-established health insurance exchanges, ruling that the phrase "an Exchange established by the State" should be interpreted to include federal exchanges to avoid destabilizing insurance markets.

Question 57

Hill v. Ohio County (1971)

Answer 57

Case establishing that under common law, hospitals have no duty to treat any specific individual, and that admission decisions are at the discretion of the trustees or governing board of a hospital.

Question 58

O'Connor v. Donaldson (1975)

Answer 58

Supreme Court case establishing that a state cannot constitutionally confine a mentally ill person who is dangerous to no one and can live safely in freedom. Mental illness alone is insufficient justification for involuntary confinement.

Question 59

Monmouth Medical Center v. Harris

Answer 59

Case that upheld the government's right to deny Medicare reimbursement to a hospital for a patient who no longer required hospital or skilled nursing care but needed custodial care, even when appropriate facilities were unavailable.

Question 60

City of Revere v. Massachusetts General Hospital

Answer 60

Supreme Court case establishing that while due process requires governments to provide medical care to persons in police custody, the Constitution does not require the government to pay for that care in the absence of state legislation.

Question 61

Dent v. West Virginia (1889)

Answer 61

First significant healthcare issue decided by the Supreme Court, upholding a state's authority to require physicians to be licensed and establishing the principle that states can regulate medical practice to protect public health.

Question 62

Guaranteed issue

Answer 62

ACA provision requiring insurers to accept every employer and individual who applies for coverage, prohibiting exclusion based on preexisting conditions.

Question 63

Individual mandate

Answer 63

ACA requirement that most Americans maintain a minimum level of health insurance coverage or pay a tax penalty (the "shared responsibility payment"). Tax penalty was reduced to $0 beginning in 2019.

Question 64

Death spiral

Answer 64

A situation in health insurance markets where premiums increase, healthy enrollees drop coverage (adverse selection), the risk pool becomes riskier, and premiums grow even faster for the remaining insured population, eventually causing market collapse.

Question 65

Hill-Burton Act

Answer 65

The Hospital Survey and Construction Act of 1946 that provided federal financing for hospital construction and modernization, requiring recipients to provide a "reasonable volume" of services to persons unable to pay (uncompensated care obligation) and ensure facilities were available to all persons in the community (community service obligation).

Question 66

Medicare Administrative Contractors (MACs)

Answer 66

Private companies that process Medicare claims on behalf of the government, receive federal money and pay providers' claims. Originally known as Part A Fiscal Intermediaries and Part B Carriers.

Question 67

Medicaid

Answer 67

A joint federal-state program that provides healthcare coverage for low-income individuals. States receive at least 50% federal funding based on a formula that includes average per capita income, resulting in over 50 separate programs with varying administrative structures, reimbursement rates, and coverage levels.

Question 68

Prospective payment system (PPS)

Answer 68

Medicare payment system established in the 1980s that pays hospitals predetermined, fixed amounts based on patients' diagnoses (diagnosis-related groups) rather than retrospectively paying for actual costs incurred.

Question 69

Managed care

Answer 69

Insurance programs that attempt to reduce healthcare costs through economic incentives, review of medical necessity, increased cost sharing, controls on admissions and lengths of stay, selective contracting with providers, and intensive management of high-cost treatments.