HPM Final Exam Lectures UPDATED
QUESTIONS AND CORRECT ANSWERS
How do individuals pay for health care - CORRECT ANSWER -through insurance
-out of pocket from income or savings
-charity care from a safety net provider
Publicly Financed Programs - CORRECT ANSWER Medicaid
Medicare
Children's Health Insurance Program
Department of Defense (active military)
Veterans Health Administration
Indian Health Services
Workers' compensation
Medicaid breakdown - CORRECT ANSWER enrollees:
Adults- 27%
Children- 49%
Disabled-15%
Elderly-20%
Where the dollars go:
Adults- 15%
Children-21%
Disabled-42%
Elderly-22%
How Providers are Paid for the
Health Services They Deliver - CORRECT ANSWER Insurance payments
,Fixed rates from Medicare & Medicaid
Negotiated rates from private insurers
Physicians often at disadvantage
Mds driven to join ppos, take salaried positions
Hospitals able to negotiate better rates
Private insurers pay the best rates
Medicaid pays the lowest rates
Prepaid Health Plans - CORRECT ANSWER include hmos, use capitated payments
and control which providers participate in their network, pcps are gatekeepers
Preferred Provider Organizations - CORRECT ANSWER discounted fee-fore-service,
plan members use a list of physicians with whom they have negotiated discounts and thus
have lower out-of-pocket costs,
Acos (Accountable Care Org) - CORRECT ANSWER ACO responsibility for care of a
population, patients are not locked in, don't really belong to it but if populations care meet
certain standards, ACO receives some sort of additional funding
Consumer-driven health care and high deductibles - CORRECT ANSWER * give you
a health savings account, pay for annual physical from health savings account which has
money you put in, pay for allergy medication, regular medical expenses, etc.
* insurance kicks in under extreme circumstances/ emergencies
* privately financed health care - CORRECT ANSWER * employer based insurance
* emerged during WWII as employer benefit
* unions pushed for medical insurance coverage as a part of employee beenefit packages
* IRS allow employers to deduct cost of employee health insurance
* covered 64% of americans in 2002, 52% in 2012
* individual insurance
* required and subsidized by the ACA
, * 16 million in 2008
* 8 million the exchanges in 2014, currently 12 million, estimate 24 million by 2024
* COBRA
* reduces gaps in insurance coverage between jobs
* employer must extend insurance for up to 18 months after the employee leaves- employee
has to pay premium though- very expensive
Diagnosis-Related Groups - CORRECT ANSWER - prospective payment for hospital
care
* hospital tells gov. What the diagnosis is and this is what we'll pay- medicaid
* hospital ALOS decreased
- prospective rates for physician payments
* relative based resource valued scale- medicare
* takes for each physician service, determines how much time and how much effort and
resources is to be used for that service and ranks all the physician services based on this scale
and values each of these units
Groups of inpatient discharges with final diagnoses that are similar clinically and in resource
consumption used as a basis of payment by the medicare program and as a result widely
accepted by others
Fixed amount up-front based on diagnosis regardless of length of stay/ actual cost of care
New Delivery Systems - CORRECT ANSWER * move from reactive to proactive
delivery
* care managers stay in touch with patients
* patients manage health issues between visits
* providers form close ties with other providers
* primary care
* mental health
* home care
* substance abuse
QUESTIONS AND CORRECT ANSWERS
How do individuals pay for health care - CORRECT ANSWER -through insurance
-out of pocket from income or savings
-charity care from a safety net provider
Publicly Financed Programs - CORRECT ANSWER Medicaid
Medicare
Children's Health Insurance Program
Department of Defense (active military)
Veterans Health Administration
Indian Health Services
Workers' compensation
Medicaid breakdown - CORRECT ANSWER enrollees:
Adults- 27%
Children- 49%
Disabled-15%
Elderly-20%
Where the dollars go:
Adults- 15%
Children-21%
Disabled-42%
Elderly-22%
How Providers are Paid for the
Health Services They Deliver - CORRECT ANSWER Insurance payments
,Fixed rates from Medicare & Medicaid
Negotiated rates from private insurers
Physicians often at disadvantage
Mds driven to join ppos, take salaried positions
Hospitals able to negotiate better rates
Private insurers pay the best rates
Medicaid pays the lowest rates
Prepaid Health Plans - CORRECT ANSWER include hmos, use capitated payments
and control which providers participate in their network, pcps are gatekeepers
Preferred Provider Organizations - CORRECT ANSWER discounted fee-fore-service,
plan members use a list of physicians with whom they have negotiated discounts and thus
have lower out-of-pocket costs,
Acos (Accountable Care Org) - CORRECT ANSWER ACO responsibility for care of a
population, patients are not locked in, don't really belong to it but if populations care meet
certain standards, ACO receives some sort of additional funding
Consumer-driven health care and high deductibles - CORRECT ANSWER * give you
a health savings account, pay for annual physical from health savings account which has
money you put in, pay for allergy medication, regular medical expenses, etc.
* insurance kicks in under extreme circumstances/ emergencies
* privately financed health care - CORRECT ANSWER * employer based insurance
* emerged during WWII as employer benefit
* unions pushed for medical insurance coverage as a part of employee beenefit packages
* IRS allow employers to deduct cost of employee health insurance
* covered 64% of americans in 2002, 52% in 2012
* individual insurance
* required and subsidized by the ACA
, * 16 million in 2008
* 8 million the exchanges in 2014, currently 12 million, estimate 24 million by 2024
* COBRA
* reduces gaps in insurance coverage between jobs
* employer must extend insurance for up to 18 months after the employee leaves- employee
has to pay premium though- very expensive
Diagnosis-Related Groups - CORRECT ANSWER - prospective payment for hospital
care
* hospital tells gov. What the diagnosis is and this is what we'll pay- medicaid
* hospital ALOS decreased
- prospective rates for physician payments
* relative based resource valued scale- medicare
* takes for each physician service, determines how much time and how much effort and
resources is to be used for that service and ranks all the physician services based on this scale
and values each of these units
Groups of inpatient discharges with final diagnoses that are similar clinically and in resource
consumption used as a basis of payment by the medicare program and as a result widely
accepted by others
Fixed amount up-front based on diagnosis regardless of length of stay/ actual cost of care
New Delivery Systems - CORRECT ANSWER * move from reactive to proactive
delivery
* care managers stay in touch with patients
* patients manage health issues between visits
* providers form close ties with other providers
* primary care
* mental health
* home care
* substance abuse
