Chapter 9

Question 0

How does managed-care integrates it’s functions?

Answer 0

Financing, insurance, delivery, and payment with one organizational setting

Question 1

What is managed care?

Answer 1

And organized approach of delivery healthcare services needed on its members and no negotiation of price of payment arrangement with providers

Question 2

What does managed care exercise?

Answer 2

Formal control on utilization

Question 3

How can managed-care also be an MCO?

Answer 3

By not using insurance company to manage risk without using a third-party and administrator to make payment

Question 4

How has the evolution of managed care changed? A-D

Answer 4

A. Health insurance
B. Contact Practice
C. PrePaid Group Practice
D. Managed Care

Question 5

In the evolution managed care how has HEALTH INSURANCE changed?

Answer 5

Capitation

Question 6

In the evolution of managed care contracts practice changed?

Answer 6

Defined enrollees, capitation, salary.

Question 7

In the evolution of managed care how had prepaid groups practice changed?

Answer 7

Comprehensive services, defined groups, capitation

Question 8

How has managed care changed in its evolution?

Answer 8

Utilization controls, comprehensive services, defined group of enrollees, capitation, discount fees, salary, limited for service, financial and serve incentives for providers

Question 9

What are the two types of managed-care organizations?

Answer 9

A. HMO: Health maintenance organization

B. PPO: preferred provider organization

Question 10

What do you HMOs and PPOs offer?

Answer 10

Offered other incentives, such as choice of provider variations of method of payment etc.

Question 11

What’s the reason for the growth of managed-care? A-D

Answer 11

A. Due to increase in premium cost
B. Uncontrolled utilization
C. Uncontrolled prices and payments due to uncontrolled billing by providers
D. Excess capacity of healthcare delivery example: empty beds in hospitals reimbursement by Medicaid

Question 12

What are the efficiencies of managed care integrating the quad functions?

Answer 12

Financing, insurance, delivery of services, payment to providers. (Eliminate the middleman insurance companies)

Question 13

Another efficient way of managed-care is by sharing risks with?

Answer 13

Sharing this with providers or by extracting discounts = utilization Control

Question 14

Another form of making managed-care efficient is coordinating what?

Answer 14

Coordination of patient services, most effective setting and procedures.

Question 15

Efficiencies of managed-care gatekeeping dose?

Answer 15

It reduces moral hazard (misuse)

Question 16

In Efficiencies of managed-care using preventative medicine helps?

Answer 16

In reducing cost of illness care overall.

Question 17

In cost control of managed care choice restriction is?

Answer 17

Is limited to physicians in the network

Question 18

In cost control of managed-care gatekeeping is?

Answer 18

The primary coordinate all healthcare services, manage utilization

Question 19

In cost control of managed care management is?

Answer 19

Manages difficulties, multi-disease patients, ex, AIDS, Lupus, etc

Question 20

In cost control of managed-care disease management is?

Answer 20

Population groups: diabetes, asthma, depression, etc.

Question 21

In cost control of managed-care pharmaceutical management is?

Answer 21

Use of formulary, tiered cost sharing ( co-pays)

Question 22

In cost control of managed care utilization review is?

Answer 22

Review of appropriateness of service rendered, concurrent and retrospective

Question 23

In control cost of managed-care practice profiling is?

Answer 23

Analyze of a practice to see if it fits in the organization