Actual Exam Flashcards
What percent of its GDP does the United States currently spend on healthcare?
22
17.6
18.2
16.6
17.6
The concept of having enough healthy individuals paying into the system to pay the cost for the sick individuals in the system is known as
Risk pooling
Economies of Scale
Umbrella Coverage
Pareto Balancing
Risk pooling
As discussed in the film, “America’s Health Insurance Crisis”, what was the key finding of Dr. Fisher’s research concerning the utilization of care?
More hospitalizations had no impact on outcomes.
More care clearly produces better outcomes.
More care does not necessarily result in better outcomes.
Areas with lower utilization of care by Medicare recipients had higher mortality rates.
More care does not necessarily result in better outcomes.
Choose the answer that accurately conveys what happened historically. The HMO Act
was passed in the early 1980’s and signed into law by Ronald Reagan.
began with a plan offered by Kaiser in California public works projects.
Came about it the 1970s when there were few checks on healthcare utilization and employers and the government were confronted with rising healthcare cost
was intentionally promoted by the government in the 1930’s after President Roosevelt opted not to include national health insurance in his social security legislation
Came about it the 1970s when there were few checks on healthcare utilization and employers and the government were confronted with rising healthcare cost
How are healthcare cost a “Hidden Tax” on all Americans?
Americans only pay co-pays and deductibles and never pay the full cost of healthcare over the counter.
Medicare and Social Security taxes are taken as payroll deductions, individuals don’t really see it.
Emergency Room expenses to care for the uninsured are paid for through payroll taxes
The cost of heath care is built into the price of everything we purchase.
The cost of heath care is built into the price of everything we purchase.
Which U S government healthcare program most resembles the healthcare system in the UK ?
Social Security
Veterans Administration
Medicare
Medicaid
Veterans Administration
Historically, where do the majority of Americans get health insurance coverage?
Medicare
Personal Insurance Plans
Unions
Employers
employers
Which is the major difference between a “traditional” indemnity health insurance policy and a managed care health insurance policy?
Indemnity health insurance policies only cover catastrophic illnesses like cancer, while managed care plans cover everything.
Those with a traditional indemnity health insurance policy can go to any provider, while those that are covered by managed care plans generally are limited to a prescribed network of providers.
Indemnity health insurance plans limit access to specific providers.
Indemnity health insurance cost less than managed care health insurance plans like PPOs and HMOs.
Those with a traditional indemnity health insurance policy can go to any provider, while those that are covered by managed care plans generally are limited to a prescribed network of providers.
What is Moral Hazard?
An insurer’s algorithm for determining the value of a life.
An insurance company’s code of ethics.
A negative outcome for the patient as a consequence of a denial of payment by the insurer.
An increase in an insurers risk arising from the insured’s indifference to loss because of the existence of insurance.
An increase in an insurers risk arising from the insured’s indifference to loss because of the existence of insurance.
The diagnostic related group is associated with
The Retrospective payment system
Capitation
Out of pocket payment
The prospective payment system
The prospective payment system
Copays and deductibles
Are not a part of HMOs
Help to reduce cost by discouraging unnecessary tests by providers
Shift financial risk to patients
Are only found in indemnity plans
Shift financial risk to patients
The name of the third party administrators contracted by the government to run the Medicare program.
TPO
Medicare Administration Agencies
CMS
Fiscal Intermediaries
Fiscal Intermediaries
A Prospective Payment System helps to control cost by
requiring prior authorization for all forms of treatment
setting the rate for reimbursement prior to the delivery of services
limiting access to specialty providers
doing concurrent utilization reviews
setting the rate for reimbursement prior to the delivery of services
Coinsurance differs from a co-payment in that
coinsurance is always less than what a copay would be.
coinsurance is a percentage of the allowed reimbursement and copays are set amounts.
coinsurance is the same as a deductible.
coinsurances are billed to the patient after the insurer pays its portion. Copays must be paid at the time services are delivered.
coinsurance is a percentage of the allowed reimbursement and copays are set amounts.
The Affordable Care Act
Addresses financial access by providing tax credits and also prohibits the exclusion of individuals with pre-existing health conditions
Addresses the high cost of premiums by directly limiting what providers are able to charge for services through annually published price caps
Addresses the issue of Moral Hazard by giving financial support directly to health insurers
Addresses both the cost and quality of healthcare by mandating prices and defining what outcomes are expected
Addresses financial access by providing tax credits and also prohibits the exclusion of individuals with pre-existing health conditionsq
Based on the material presented in class which of the following is true of the US healthcare system?
The federal government is the only financial risk bearer in American system
It offers equal access to care to all citizens
It is one of the most expensive and decentralized system in the world.
It performs well in delivery of care to every segment of the population
It is one of the most expensive and decentralized system in the world.
A capitated plan
Pays providers a flat rate per patient case
pays providers based on a fee for service basis
Pays providers a set amount per person they serve per period of time
Pays providers based on contract rates negotiated annually with Medicare
Pays providers a set amount per person they serve per period of time
What area of the healthcare system accounts for approximately 1/3 of healthcare spending?
Hospitals
Skilled Nursing
Pharmaceuticals
Outpatient care
Hospitals
How would utilization costs likely be impacted in an area with higher numbers of specialists and/or hospital beds compared to areas with lower numbers of specialists and/or hospital beds.
Utilization costs would likely be higher in the area with more specialists and/or more hospital beds.
Utilization costs would be lower due to competition between providers in the area with more specialists and/or hospital beds.
Increased numbers of hospital beds would have no effect. The increased number of specialists could raise utilization costs.
The numbers of doctors and amount of resources like hospital beds have no influence on utilization costs.
Utilization costs would likely be higher in the area with more specialists and/or more hospital beds.
Does the change in healthcare cost between 1960 and 2008 help to explain the increasing number of uninsured during the same period?
Yes. The cost of healthcare grew at a rate equal to GDP, but insurers made coverage harder to get.
No. Cost is tied to quality but not access.
Correct!
Yes. The cost of healthcare grew faster then the growth of GDP during the same period of time.
No. Healthcare cost had no impact on the growth in the number of uninsured..
Yes. The cost of healthcare grew faster then the growth of GDP during the same period of time.
Which of the following is an accurate list of the categories of sources that pay for healthcare.
Taxes credits, employer coverage, individual coverage and military coverage
Out-of-pocket payments, private health insurance and public health insurance
Tax credit reimbursement and individual payments
Self-insured and employer coverage
Out-of-pocket payments, private health insurance and public health insurance
Concerning the continuum of managed care, which of the following statements is true
Insurers on the far left of the continuum have complete control over cost and quality
Traditional indemnity plans appear in the middle of the continuum
As you move across the continuum, insurers’ level of control over costs and control over quality changes.
Traditional HMO’s appear in the middle of the continuum
As you move across the continuum, insurers’ level of control over costs and control over quality changes.
The key ideas underlying the concept of insurance
Risk Pooling and deductibles
Moral hazard and cost
access, cost and quality
Risk transfer and risk pooling
Risk transfer and risk pooling
Which statement best reflects how retrospective fee-for-service works?
Providers receive compensation based on the number of patients they are charged with caring for and receive a set amount per patient per year.
Providers are paid for each test or procedure they do and are paid after they provide the services.
Providers receive a fixed amount, based on the patient’s diagnosis, regardless of how much care they provide the patient.
Providers are paid based on the outcomes they produce.
Providers are paid for each test or procedure they do and are paid after they provide the services.
Displayed on a graph the relationship between cost and quality shows that
At a point, the line levels out showing that quality is no longer improving
the line ascends to a point and turns down indicating that quality begins to decline with greater spending
quality continues to improve as you spend more
The line is erratic and rises and falls depending on the spending amount.
At a point, the line levels out showing that quality is no longer improving
Which of the following statements is true concerning the labels attached to health plans (PPO, HMO…)
The label given to a plan can be relied upon to indicate where a plan falls on the continuum of managed care
Plans labeled PPO are always on the center of the continuum of managed care
Because the actual features of the plan are unknown until confirmed, it is impossible to know where a plan lies on the continuum of managed care based on its label
The level of control over cost and quality that an insurer has can always be reliably determined by the label applied to the insurance plan
Because the actual features of the plan are unknown until confirmed, it is impossible to know where a plan lies on the continuum of managed care based on its label
Which of the following managed care mechanisms transfers risk to the insured
Prospective payment
DRG
Deductible
Capitated payment
Deductible
Which of the following managed care mechanisms transfers risk to the healthcare provider
Capitation
Deductible
Risk pooling
Co-pay
Capitation
How does ongoing training and continuing education support patient care risk management?
It improves patient education efforts
It supports the maintenance of current knowledge
Reduces compliance errors related to informed consent
Helps with patient adherence
It supports the maintenance of current knowledge
The acronym that refers to the graphical point where risk is managed to be as low as we can practically make it.
LRP
DRG
ALARP
SRAM
ALARP
What ideas in the responses below represent major influences on the development of insurance during the 20th century?
The cost of healthcare began to rise and group insurance began to be offered as an employee benefit.
Advances in computer technology, benefit tax law and social unrest
The rise of organized labor and government moderated labor negotiations
WWI and WWII
The cost of healthcare began to rise and group insurance began to be offered as an employee benefit.
The objective of a cost effective risk management program should be to
Spend whatever amount is required to reduce the likelihood of preventable and unpreventable risk exposures
Eliminate all risk
Address those risks that it makes economic sense to attempt to reduce
Reduce all risk that clearly exist today
Address those risks that it makes economic sense to attempt to reduce
Which of the following best represents an example of structural improvement in a hospital?
Developing a patient education program
Increasing the use of hand hygiene practices
Upgrading the hospital’s intensive care unit with advanced technology
Measuring patient readmission rates
Upgrading the hospital’s intensive care unit with advanced technology
What did the IOM report “To Err is Human” reveal about the US healthcare system?
Poor healthcare worker performance was the source of problems in the system
Only spending more money could solve safety problems
Errors occur because the system lacked sufficient safe guards and reliability
Errors in healthcare were only sporadic and not a major concern
Errors occur because the system lacked sufficient safe guards and reliability
Which strategy below aims to reduce healthcare costs by restricting access?
Expanding health insurance coverage
Offering free preventive care
Implementing high deductible health plans
Increasing provider payment rates
Implementing high deductible health plans
A key concept in continuous quality improvement is
timeliness
controlling variation
Organizational discipline
delighting the customer
controlling variation
Which of the following is NOT an element of Continuous Quality Improvement
employee empowerment
Assurance checks for product or service defects after the product or service are delivered
Using data to make all improvement decisions
Focus on the customer
Assurance checks for product or service defects after the product or service are delivered
Risk identification can be aided by
Regular CPR training
Reports and surveys from accrediting bodies such as the Joint Commission and NCQA and professional ethics documents
The employee handbook
Insurance premiums rate changes
Reports and surveys from accrediting bodies such as the Joint Commission and NCQA and professional ethics documents
Risk management methods consist of
Long and short term approaches
Team empowerment and communication
Risk control methods and risk financing methods
Handoff activities
Risk control methods and risk financing methods
Which of the following best describes a highly reliable healthcare system?
Delivers the standard of care consistently despite complex environmental challenges
A system that requires that no unusual activity occurs to function
The system is expected to perform effectively only 90% of the time
Delivers care without patient feedback
Delivers the standard of care consistently despite complex environmental challenges
The most common type of civil litigation that is brought against audiologists
Unintentional tort of negligence
Intentional Tort type B
Action in contract
Project Medical Tort
Unintentional tort of negligence
In order for a cause of action of negligence to be pursued, four elements must be present:
A legal duty must exist, a breach of legal duty must exist, a proximate cause (i.e., cause and effect relationship) must exist between the breach of duty and the injury, an actual loss or damage must result from the injury
Parties must both have represenation, a breach of legal duty must exist, the court must accept the claim, witnesses must be called
A legal duty must exist, proximate cause must be determined, both parties must have representation, arbitration must have failed
Proximate cause must be determined, injury must persist, prompt action, plaintiff must submit to questioning
A legal duty must exist, a breach of legal duty must exist, a proximate cause (i.e., cause and effect relationship) must exist between the breach of duty and the injury, an actual loss or damage must result from the injury
In the Institute of Medicine’s definition of quality, the phrase desired health outcomes focuses on
the values that individuals place on various health outcomes and how these may differ among individuals
the outcomes sought by the healthcare system
what the evidence based research tells us about possible outcomes
health professionals’ outcome expectations
the values that individuals place on various health outcomes and how these may differ among individuals
The two most important factors influencing a practitioner’s ability to reduce exposure to liability are
Emotional disposition and Intellect
Insurance and Timing
Clinical skill and Personality
Awareness and Education
Awareness and Education
Which of the following is a model of oversight used in healthcare
Listing
Combing
Check up
Accreditation
accreditation
In terms of the types of problems that can occur in healthcare quality, medication errors are
misuse
triggers
alerts
variants
misuse
What is the “Duty of Reasonable Care”?
The patient’s obligation to accept or reject the care offered
The clinician’s responsibility to deliver the standard on care
The provider’s responsibility to ensure patient safety in the facility
The clinician’s obligation to not exceed usual and customary fees
The clinician’s responsibility to deliver the standard on care
A Duty of Reasonable Care comes into existence when
Anytime an interaction causes a clinician to use their clinical knowledge
A clinician accepts someone as a patient
Payment is made for the care administered
A clinician responds to a question regarding an individual’s health
A clinician accepts someone as a patient
Which part of Donabedian’s quality model does CQI focus on?
Outcomes
Systems
Structure
Process
process
Which of the following explains James Reason’s proposed image of “Swiss cheese” to explain the occurrence of system failures, such as medical errors?
The holes represent gaps in knowledge
In a complex system, hazards are prevented from causing harm by a series of barriers.
Blame culture has limited impact on employee behavior
He liked Swiss Cheese
In a complex system, hazards are prevented from causing harm by a series of barriers.
