Utilization patterns and the cost of health care
- Medicaid plans face several operational challenges, including challenging populations and an uncertain policy and payment environment.
- Sandy is the new practice manager of Precise Physicians group. Part of her new role is to explain the goal of managed care, in order to educate staff on its purpose and how it impacts the business’ activities and reimbursement strategies. If you were Sandy you would explain that the goal of managed care activities include all but the following?
- manage the cost of health care
- provide free healthcare service to the uninsured
- influence the quality of that health care
- provide better access to that care
- Data analysis is a powerful asset to businesses and individuals, to be able to compare information for decision making. But in order to be considered useful for data analysis purposes, data must be all of the following except:
- Be clean and valid
- Encompass a specific and short time period
- Link appropriately if it comes from multiple sources
- Be consistent and mean the same thing from
- provider to provider
- Which of the following scenarios BEST describes how capitation works in regard to physician reimbursement?
- A physician is paid the same amount regardless of how many members receive services in a given month or how expensive those services are.
- A physician is paid based on use of services by members or race or gender.
- A physician rate can vary depending on such factors as age, gender, current health status, geography, and practice type.
- None are correct
- Administrative claims data can serve many different uses for reporting and analysis in managed care. Which of the following examples BEST describes possible uses of this data:
- Monitor utilization patterns and the cost of health care
- Conduct clinical investigations
- Patient profiling
- None are correct
- Which of the following calculation scenarios describe capitation in regard to physician reimbursement?
- If a physician receives $100 per month per member and the plan has 20 members, then the physician will receive $2000/month.
- Even if no members seek services in a given month, the physician is still compensated $2000.
- On the other hand, if all 20 members seek services in a given month, the physician is still only paid $2000.
- All are correct
- In most situations, providers have the option whether or not to participate in P4P programs though involuntary participation is possible. This may be a reflection of the idea that most of pay-for-performance (P4P) incentives are financial.
- Which of the following is NOT a descriptive element of a P4P program?
- A variety of measures can be used; measures may be simple or complex; it is recommended that measures be straightforward, understandable, and valid.
- Rewards include the following: tiering, reimbursement adjustments, and bonus payments
- A common method of per diem is straight per diem; this method is a negotiated single charge for a day in the hospital regardless of any actual charges or costs incurred.
- None are correct
- Managed care organizations have a wide array of tools to promote prevention through the use of activities, such as case management. To achieve maximum impact, managed care organizations need to make use of the entire set of tools available to them. Components of a strong managed care prevention program include the following.
- immunizations and screenings included in benefits
- health risk assessments for select populations only
- free fitness center memberships
- none are correct
- The following should be considered when designing and implementing technology and information systems:
- Visibility, because only external customers should be considered.
- Security and privacy, because employees should be individually responsible for security audits.
- Usability, because users’ needs should not be met.
- Flexibility, because systems should have the capability to be easily modified to meet changing requests.
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