GBA 1 - STUDY GUIDE QUESTIONS AND ANSWERS
What was the purpose of the Health Maintenance Organization Act of 1973? -
ANSWER-The health maintenance organization action of 1973 provided federal
initiatives - consisted of federal grants and loans to organizations wishing to
investigate the feasibility of "federally qualified HMO"
How did the passage of the Health Maintenance Organization Act of 1973 affect
the growth of HMOs? - ANSWER-The government began to withdraw its funding
during the Reagan administration. Smaller plans did not survive.
Briefly explain why the preferred provider organization (PPO) concept was
developed? - ANSWER-PPO was sponsored by national insurance companies,
third party administrators, BCBS plans, and hotel organizations. PPO gained
quick popularity with employers that wanted cost savings but were unwilling to
reduce provider choice as much that required HMOs
Why didnt many employers realize long-term costs savings with PPO? -
ANSWER-Because they were primarily discounted fee-for-service arrangements
with little focus on utilization control.
What steps did PPO companies take to correct this problem? - ANSWER-Increase
the monitoring of utilization, implementing quality control and surveying
member satisfaction.
, What do opponents of the PPO approach argue is the reason they are more
expensive than HMOs? - ANSWER-They argue that PPOs are weak form of
managed care with rich benefits, making them more expensive than HMOs.
Is there a universally accepted and used definition of managed care? - ANSWER-
There is no specific and uniformly accepted definition of the term "managed
care"
What is the definition of managed care provided in the text to include the broad
range of managed indemnity plans, HMOs, PPOs, and PO plans? - ANSWER-
Managed care includes those programs intended to influence and direct the
delivery of health care through: 1) plan design failure 2) Restricted access to a
specified group of preselected providers 3) Utilization management programs
Define the concept of steerage - ANSWER-Is the managed care company's way of
directing members to in-network providers. Commonly accomplished through
setting benefit differentials between in-and out-of-network care between 10%-
30%. It is critical to maximize financial results of managed care.
Utilization Management (UM) prgrams - ANSWER-1) Precertification of inpatient
admissions
2)Concurrent review of ongoing confinements for medical necessity
3)Discharge planning
4)Precertification for selected outpatient services
5)Second surgical opinion
6)Case management for high-dollar cases
What was the purpose of the Health Maintenance Organization Act of 1973? -
ANSWER-The health maintenance organization action of 1973 provided federal
initiatives - consisted of federal grants and loans to organizations wishing to
investigate the feasibility of "federally qualified HMO"
How did the passage of the Health Maintenance Organization Act of 1973 affect
the growth of HMOs? - ANSWER-The government began to withdraw its funding
during the Reagan administration. Smaller plans did not survive.
Briefly explain why the preferred provider organization (PPO) concept was
developed? - ANSWER-PPO was sponsored by national insurance companies,
third party administrators, BCBS plans, and hotel organizations. PPO gained
quick popularity with employers that wanted cost savings but were unwilling to
reduce provider choice as much that required HMOs
Why didnt many employers realize long-term costs savings with PPO? -
ANSWER-Because they were primarily discounted fee-for-service arrangements
with little focus on utilization control.
What steps did PPO companies take to correct this problem? - ANSWER-Increase
the monitoring of utilization, implementing quality control and surveying
member satisfaction.
, What do opponents of the PPO approach argue is the reason they are more
expensive than HMOs? - ANSWER-They argue that PPOs are weak form of
managed care with rich benefits, making them more expensive than HMOs.
Is there a universally accepted and used definition of managed care? - ANSWER-
There is no specific and uniformly accepted definition of the term "managed
care"
What is the definition of managed care provided in the text to include the broad
range of managed indemnity plans, HMOs, PPOs, and PO plans? - ANSWER-
Managed care includes those programs intended to influence and direct the
delivery of health care through: 1) plan design failure 2) Restricted access to a
specified group of preselected providers 3) Utilization management programs
Define the concept of steerage - ANSWER-Is the managed care company's way of
directing members to in-network providers. Commonly accomplished through
setting benefit differentials between in-and out-of-network care between 10%-
30%. It is critical to maximize financial results of managed care.
Utilization Management (UM) prgrams - ANSWER-1) Precertification of inpatient
admissions
2)Concurrent review of ongoing confinements for medical necessity
3)Discharge planning
4)Precertification for selected outpatient services
5)Second surgical opinion
6)Case management for high-dollar cases
