US Healthcare Systems Exam 2 Questions and Answers
With a capitation payment system- who holds all the risk - -the provider
-Why did managed care not control cost? - -page 357
-True or False. Most people prefer to stay in their homes for long term care - -True 73%
prefer to stay in their homes
-Explain Pay for Performance - -Value Based reimbursement that links quality and
efficiency
GOAL- Improve Quality/ decrease cost
-What is adverse selection? - -Occurs when higher risk individual enroll in healthcare
plans
i.e. premiums increase for everyone
-What is favorable selection? - -Occurs when low risk or healthy people enroll in
healthcare plans.
-What is cream skimming - -plans selectively enroll healthy people and avoid sick
people...for example advertising at a gym
-What is cost shifting? - -providers charge extra to payers who do not exercise good cost
control, usually to cover uncompensated care
-True or False. HIPPA established a health care fraud and abuse program - -true
-True or False. Managed care has increase demand - -true
-True or False. Managed care has led to organizational intergration - -true
-About ___% of older Americans will need long term care at one point in their lives - -70%-
most get the care in their homes
-About ___% of long term care are under the age of 65 - -37%
-Who is the biggest payer in long term care? - -2/3 of long term care is paid by medicaid
-Explain the evolution of managed care? - -Became successful due to the failure of fee for
service and uncontrolled cost
-How does managed care integrate the financing portion of the quad function? - -contract
negotiations between employer and MCOs
,-How does managed care integrate the insurance portion of the quad function? - -MCO
assumed risk
medical loss ratio= % of revenue between employers and MCOs
-How does managed care integrate the delivery function of the quad function? - -services
by providers contracted with MCOs
-How does managed care integrate the payment function of the quad function? - -3 ways
capitation, discounted fees, salary
each provide risk sharing with provider to control cost
-Characteristics of MCO
Focus on quad function limiting cost finance, insurance, delivery and payment - -LIMIT
CHOICE ON PROVIDER
UTILIZATION MANAGEMENT
financial incentives for efficiency
gatekeeper
risk sharing
-How did MCO emerge in history? - --AMA Opposition to prepaid medicine violated
sherman antitrust act
-HMO Act of 73 provided federal funds to start new HMOs
tricky dick?
-Where does physical therapy fall in the level of care continuum - -restorative care
-The three factors of HMO growth - -1. flaw in fee for service
2. cost appeal
3. Weakened economic position of providers
-Identify some types of community based long term care services on test find the one that
does not fit - -Home health care
Adult day care
Adult foster care
Senior centers
Home-delivered and congregate meals
Homemaker services
Continuing Care at Home
Case management
-Name the Five quality of life in long term care - -A multifaceted concept
Lifestyle pursuits
Living environment
Clinical palliation
Human factors
, Personal choices
-True or False. mental illness is prevalent among 25% of elderly - -true
-Most common cause of dementia in elderly - -Progressive and irreversible decline in
cognition, thinking, and memory
15% of people age 70 and over have dementia
Alzheimer's disease is the most common - affects 5 million elderly in the United States
40% of those with dementia need institutional care
-What is the main goal of long term care services - -Main goal of preventive LTC is to
prevent or delay institutionalization
Various community-based LTC services have a preventive function
Therapeutic services include nursing care, rehabilitation, and therapeutic diets
-What is the difference in informal and formal care in long term services? which type of
care is more popular - -Informal:
Nonreimbursed care by family and friends
Most LTC in the US is informal
Insufficient informal care is associated with higher all-cause mortality, hospitalization, and
institutionalization
Issue
Shrinking pool of informal caregivers
-2/3 of long term care is paid by medicaid, how much of assisted living is private pay? - -
Assisted Living Facilities (ALFs)
86% of the residents pay privately
-Familiarize yourself with level of care continuum in long term care - -Personal care—
basic ADL assistance (e.g., bathing)
Custodial care—nonmedical care to maintain function and prevent decline
Restorative care—help regain or improve function; professional therapies
Skilled nursing care—clinical care provided by licensed nurses under the direction of a
physician
Subacute care—postacute, technically complex services
-What is HCBS? - -Both private and public financing
Older Americans Act, 1965 provides federal funds to states
Overseen by the federal Administration on Aging
Section 1915(c) waivers (to the Social Security Act) enable states to provide community-
based LTC under Medicaid
Title XX Social Services Block Grants are also used for community-based LTC
Medicaid Personal Care Services Program (limited)
Issues
Needs go unmet; inadequate workforce; transportation barriers; limited supportive
housing
With a capitation payment system- who holds all the risk - -the provider
-Why did managed care not control cost? - -page 357
-True or False. Most people prefer to stay in their homes for long term care - -True 73%
prefer to stay in their homes
-Explain Pay for Performance - -Value Based reimbursement that links quality and
efficiency
GOAL- Improve Quality/ decrease cost
-What is adverse selection? - -Occurs when higher risk individual enroll in healthcare
plans
i.e. premiums increase for everyone
-What is favorable selection? - -Occurs when low risk or healthy people enroll in
healthcare plans.
-What is cream skimming - -plans selectively enroll healthy people and avoid sick
people...for example advertising at a gym
-What is cost shifting? - -providers charge extra to payers who do not exercise good cost
control, usually to cover uncompensated care
-True or False. HIPPA established a health care fraud and abuse program - -true
-True or False. Managed care has increase demand - -true
-True or False. Managed care has led to organizational intergration - -true
-About ___% of older Americans will need long term care at one point in their lives - -70%-
most get the care in their homes
-About ___% of long term care are under the age of 65 - -37%
-Who is the biggest payer in long term care? - -2/3 of long term care is paid by medicaid
-Explain the evolution of managed care? - -Became successful due to the failure of fee for
service and uncontrolled cost
-How does managed care integrate the financing portion of the quad function? - -contract
negotiations between employer and MCOs
,-How does managed care integrate the insurance portion of the quad function? - -MCO
assumed risk
medical loss ratio= % of revenue between employers and MCOs
-How does managed care integrate the delivery function of the quad function? - -services
by providers contracted with MCOs
-How does managed care integrate the payment function of the quad function? - -3 ways
capitation, discounted fees, salary
each provide risk sharing with provider to control cost
-Characteristics of MCO
Focus on quad function limiting cost finance, insurance, delivery and payment - -LIMIT
CHOICE ON PROVIDER
UTILIZATION MANAGEMENT
financial incentives for efficiency
gatekeeper
risk sharing
-How did MCO emerge in history? - --AMA Opposition to prepaid medicine violated
sherman antitrust act
-HMO Act of 73 provided federal funds to start new HMOs
tricky dick?
-Where does physical therapy fall in the level of care continuum - -restorative care
-The three factors of HMO growth - -1. flaw in fee for service
2. cost appeal
3. Weakened economic position of providers
-Identify some types of community based long term care services on test find the one that
does not fit - -Home health care
Adult day care
Adult foster care
Senior centers
Home-delivered and congregate meals
Homemaker services
Continuing Care at Home
Case management
-Name the Five quality of life in long term care - -A multifaceted concept
Lifestyle pursuits
Living environment
Clinical palliation
Human factors
, Personal choices
-True or False. mental illness is prevalent among 25% of elderly - -true
-Most common cause of dementia in elderly - -Progressive and irreversible decline in
cognition, thinking, and memory
15% of people age 70 and over have dementia
Alzheimer's disease is the most common - affects 5 million elderly in the United States
40% of those with dementia need institutional care
-What is the main goal of long term care services - -Main goal of preventive LTC is to
prevent or delay institutionalization
Various community-based LTC services have a preventive function
Therapeutic services include nursing care, rehabilitation, and therapeutic diets
-What is the difference in informal and formal care in long term services? which type of
care is more popular - -Informal:
Nonreimbursed care by family and friends
Most LTC in the US is informal
Insufficient informal care is associated with higher all-cause mortality, hospitalization, and
institutionalization
Issue
Shrinking pool of informal caregivers
-2/3 of long term care is paid by medicaid, how much of assisted living is private pay? - -
Assisted Living Facilities (ALFs)
86% of the residents pay privately
-Familiarize yourself with level of care continuum in long term care - -Personal care—
basic ADL assistance (e.g., bathing)
Custodial care—nonmedical care to maintain function and prevent decline
Restorative care—help regain or improve function; professional therapies
Skilled nursing care—clinical care provided by licensed nurses under the direction of a
physician
Subacute care—postacute, technically complex services
-What is HCBS? - -Both private and public financing
Older Americans Act, 1965 provides federal funds to states
Overseen by the federal Administration on Aging
Section 1915(c) waivers (to the Social Security Act) enable states to provide community-
based LTC under Medicaid
Title XX Social Services Block Grants are also used for community-based LTC
Medicaid Personal Care Services Program (limited)
Issues
Needs go unmet; inadequate workforce; transportation barriers; limited supportive
housing
