An Introduction to the Basic Managed Care Concepts
Post Study Examination
Managed care differs from traditional forms of insurance because it:
a) may limit the level of freedom that patients have to choose their health care provider
b) manages the cost and quality of the healthcare services provided, while simultaneously controlling access to those services
c) may create financial incentives to choose one provider over another
d) all of the above
What are the main forces which contribute to the growth of managed care?
demand for lower cost care
federal healthcare reform regulations
demand for higher quality care
demand for accountability for the care provided
the growth of the elderly population
a)
1, 2, 3, & 5
b)
3, 4, & 5
c)
1, 3, 4
d)
2, & 5
Managed care organizations must perform a balancing act. They must perform a balancing act between maintaining quality and controlling costs.
a) true
b) false
Hospitals who have had experience with managed care organizations have noticed which of the following:
reduced hospital operating costs
a decrease in the number of inpatient admissions
an increase in the number of patient days
a decrease in the number of patient days
streamlined hospital systems
a)
1, 2, 3, & 5
b)
2, 4, & 5
c)
1, & 4
d)
2, 4
Managed care organizations can restrain the amount of money they pay out for hospital services by establishing fixed fee schedules for specific medical procedures.
a) true
b) false
In a ______ arrangement, the managed care organization pays the hospital full charges or a discount of charges.
a) per case
b) capitation
c) per diem
d) fee-for-service
In a ______ arrangement, the managed care organization pays the hospital a fixed lump sum payment for all services performed per episode of hospitalization
a) per case
b) capitation
c) per diem
d) fee-for-service
In a ______ arrangement, the managed care organization pays the hospital a fixed lump sum payment for each day a patient is in the hospital, regardless of the actual costs incurred by the hospital.
a) per case
b) capitation
c) per diem
d) fee-for-service
In a ______ arrangement, the managed care organization pays the hospital a pre-determined amount for a defined patient population for a specific time period to cover all hospital costs, regardless of whether the patients actually utilize hospital services.
a) per case
b) capitation
c) per diem
d) fee-for-service
Stage I of the managed care evolutionary process can be characterized as:
a) freedom to choose where and who provides their care
b) managed care penetration is moderate to high > 20%
c) providers are usually reimbursed under a per case arrangement
d) formalized integrated delivery systems
Stage II of the managed care evolutionary process can be characterized as:
a) HMO penetration is between 10-30%
b) providers are paid on a fee-for-service or discount of charges basis
c) only a few dominant HMOs exist
d) formalized integrated delivery systems
Stage III of the managed care evolutionary process can be characterized as:
a) only a few managed care organizations in each regional market
b) physicians are reimbursed on a capitated basis; hospitals are reimbursed on a per diem or per case basis
c) direct employer/provider contracts
d) patients have freedom of choice in regards to providers
Stage IV of the managed care evolutionary process can be characterized as:
a) fully integrated networks
b) provider reimbursement on a per diem basis
c) HMO penetration < 30%
d) patients have freedom of choice in regards to providers
Many hospitals are developing partnerships through integration. Integration is taking place in response to growing pressure from market forces from changes in the healthcare delivery system.
a) true
b) false
Information systems for the hospital need to be developed to assist in the:
a) identification of managed care contracts that are losing the hospital money
b) ability of the hospital to negotiate and execute managed care contract terms efficiently
c)easily identify and track payments
d) all of the above
There are several strategies that a hospital and its individual departments may pursue to prepare for managed care. These include:
reduce the number of beds in your hospital
join or build integrated networks
measure and improve quality
reduce costs & re-engineer all operations of the hospital
invest in an information systems
reduce the number of physicians who have admitting privileges at your hospital
measure and improve customer satisfaction
sign as many managed care contracts as soon as possible
increase patient volume to your hospital and increase length of stay
a)
1, 3, 4, 9
b)
4, 6, 8, 9
c)
1, 2, 3, 4, 5, 7
d)
1, 2, 4, 6, 9
e)
2, 3, 4, 5, 7
f) all of the above
Hospitals should not only consider its patients as customers, but it should also consider the managed care organizations themselves as its customers.
a) true
b) false
Managed care organizations continue to shift financial risk toward providers
a) true
b) false
Historically, several important factors have contributed to the upward spiral of healthcare costs. These include:
a) rapid introduction of high technology medicine
b) insurance companies have passed on the costs of increased utilization to employers in the form of premium rate hikes
c) broad insurance coverage has encouraged consumers to use medical care with little regard for price
d) all of the above
Re-engineering is a process by which the hospital moves from a process oriented method of operation in which individual departments, such as finance, nursing, purchasing, etc. come together to work cross-functionally to accomplish certain performance objectives to method by which hospital departments are seen as distinct and independent functional areas of operations such as nursing, administration, purchasing, etc.
a) true
b) false
Managed care organizations encompass a broad spectrum of models for care delivery and management.
a) true
b) false
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Kathryn Barry, Director
Healthcare Marketing Department
United States Surgical Corporation
150 Glover Avenue
Norwalk, Connecticut 06856