Ch. 4 Working in Today’s Health Care Environment

Question 1

MCO

Answer 1

• Managed Care Organization (MCO)
  
  • Gatekeeper— Primary physician

Question 2

HMO

Answer 2

• Health Maintenance Organization (HMO)
  
  • Offers a wide range of services to members for a predetermined fee by a limited group of providers
    
    • Capitation rate

Question 3

PPO

Answer 3

• Preferred Provider Organization (PPO)
  
  • Patient must use a medical provider who is under contract with the insurer for an agreed-upon fee
    
    • Copayment

Question 4

EPO

Answer 4

• Exclusive Provider Organization (EPO)
  
  • Combines the concepts of HMO and PPO
  • Modified fee for service (FFS)

Question 5

Medicare..

Answer 5

• Health care coverage for elderly or seriously disabled, or with end-stage renal disease, or other debilitating ailments, regardless of wealth or income
• Rationing of health care

Question 6

Problems with Medicare:

Answer 6

• High cost and deductible
• Not accepted by all doctors

Question 7

DRGs

Answer 7

• Diagnostic Related Groups (DRGs)
  
  • Classifies each medicare patient by illness into a category
  • Hospitals receive a preset sum for a treatment of an illness category
    
    • Regardless of “bed days” used
  • Discourages treatment of severely ill patients
    
    • Patients often are discharged before ready

Question 8

Medicaid

Answer 8

• For the poor and indigent
• A joint Federal-State program
  
  • Federal government pays 57% of expenditures
• Federal program implemented by individual states
• Rationing takes place

Question 9

Problems with Medicaid:

Answer 9

• Not all providers accept Medicaid coverage
• Individual states enact their own legislation regarding spending

Question 10

Ethical Considerations of Managed Care

Answer 10

• Some physicians will not treat Medicare patients
• Must provide minimum standard of care to everyone
• Patients must be fully informed of consequences of obtaining health care elsewhere
• Bait-and-switch— Not all cost are covered
• Profit may be more important than patient’s health
• Wealthy may have greater access to care and treatment than poor patients

Question 11

Health Care Quality Improvement Act (HCQIA) of 1986

Answer 11

• Passed out of concern about medical malpractice
• Protects whistleblowers
• National Practitioner Data Bank (NPDB)
  
  • Information not disclosed to general public

Question 12

Solo Practice

Answer 12

• Sole Partnership

Question 13

Partnership

Answer 13

• Share responsibility for financial and legal matters

Question 14

Associate practice

Answer 14

• Share facility, but not accounting or legal responsibility

Question 15

Group practice

Answer 15

• Three or more physicians
• Share same facility
• Practice medicine together
• Can be designated as HMO or IPA

Question 16

Professional corporations

Answer 16

• Managed by board of directors
• Shareholders
• Protection of individual assets and liability

Question 17

Fee splitting

Answer 17

• One physician offers to pay another for referral (unethical and illegal)

Question 18

Franchise

Answer 18

• Business run by individual to whom franchisor grants exclusive right to market product or service in certain market area (ethical)

Question 19

Franchisees

Answer 19

• Persons or companies that hold a franchise

Question 20

Medical Specialty Board

Answer 20

• 23 specialty boards
• Seek to improve quality of medical care
• Encourage physicians to further education and training
• Evaluate candidates who apply and pass exam
• Board-certify those who pass
• American College of Surgeons
  
  • Fellow of American College of Surgeons (FACS)
• American College of Physicians
  
  • Fellow of American College of Physicians (FACP)

Question 21

Licensed personnel include

Answer 21

• Registered nurse
• Nurse practitioner
• Licensed practical nurse
• Pharmacist

Question 22

Certified personnel include:

Answer 22

• Physician assistant
• Medical assistant
• Medical transcriptionist
• Lab technician
• Lab technologist

Question 23

Registered personnel include

Answer 23

• Nurses
• Medical assistants
• Medical technologist
• Phlebotomist

Question 24

Conscience Clause

Answer 24

• Enacted by several states
• Employees may have a moral or religious objection to assisting with certain procedures (sterilization, abortion)
• Employee cannot be discriminated against under the state’s statute