Prof quiz 3 hints, part 3

Question 1

What fraction of total hospital costs is between ages 45 and 84?

Answer 1

2/3

Question 2

What are the two main cost drivers in hospitals?

Answer 2

Intensity of svcs (cost per day)
Pop growth

Question 3

What contributed to the hospital downsizing from the mid-1980s onward?

Answer 3

Changes in reimbursement
Impact of managed care
Hospital closures

Question 4

How did changes in reimbursement contribute to hospital downsizing in the mid-1980s onward?

Answer 4

From cost-plus to prospective payment system (PPS)
Decrease in inpt utilization

Question 5

How did managed care impact hospital downsizing from the mid-1980s onward?

Answer 5

Emphasis on cost containment
Efficient utilization of resources (care in alternative settings)

Question 6

Describe hospital closures that occurred in the mid-1980s onward?

Answer 6

Economic constraints
Many rural and urban hospitals had to close
Other hospitals closed wings or used them for alternative purposes

Question 7

What is ALOS an indicator of?

Answer 7

Severity of illness and resource use

Question 8

Types of public access hospitals

Answer 8

Community
Non-community

Question 9

What percentage of the hospitals in 2014 were private non-profit or voluntary?

Answer 9

Over 50%

Question 10

Types of choice restriction in MCOs

Answer 10

Closed panel
Open access

Question 11

Definition of closed panel

Answer 11

In-network access
No access outside the panel

Question 12

What does utilization review ensure?

Answer 12

Appropriate levels of svcs are delivered
Care is cost-efficient
Subsequent care is planned

Question 13

What are the three main types of utilization review by the time when the review is undertaken?

Answer 13

Prospective UR
Concurrent UR and d/c planning
Retrospective UR

Question 14

Aspects of practice profiling

Answer 14

Evaluate provider-specific practice patterns
Profile monitoring
Compare to a norm
Feedback to change behavior
Goal: improve quality and efficiency
Somewhat controversial

Question 15

Aspects of HMOs

Answer 15

Both medical care for illness and preventive care
PCP as gatekeeper
Capitation
In-network access (except hybrid and triple-option plans)
Carve outs for special svcs
Required to comply with standards of quality

Question 16

Aspects of PPOs

Answer 16

Contracts with a grp of physicians and hospitals
Open-panel option
Discounted fee arrangement with providers (no direct risk sharing)
Fewer restrictions to the care seeking behaviors: no gatekeeping and other controls

Question 17

Aspects of POS

Answer 17

HMO features: gatekeeping utilization controls, capitation
PPO feature: open access option available at the point of svc
Later, the need for POS plans became less important

Question 18

Managed care’s effect on quality

Answer 18

Overall, quality of care in MCO plans = traditional FFS
No evidence of skimping on care bc of capitation
Lower quality in for-profit plans vs non-profit plans
Enrollees of Medicare Advantage have a higher likelihood of rehopsitalization compared to those in original Medicare

Question 19

Backlash, regulation, and aftermath on quality in managed care

Answer 19

Backlash from consumers, physicians and legislators led to regulations against managed care
Relaxed utilization controls
More bargaining power to providers
Organizational integration

Question 20

Case management and MCOs

Answer 20

Coordination of care for complex and potentially costly cases
A variety of svcs from multiple providers over an extended period
Coordination of an individual’s total HC in consultation with primary and secondary care providers by an experienced HC professional, such as an NP

Question 21

Service strategies in managed care

Answer 21

Horizonal integration
Vertical integration

Question 22

Horizontal integration

Answer 22

Extends core product or svc
To control the geographic distribution of a certain type of HC svc
Not for diversification

Question 23

What does Medigap cover?

Answer 23

The high out of pocket costs in the original Medicare program

Question 24

To whom is Medigap not available to? What does it not cover?

Answer 24

Those covered by Medicaid or Medicare advantage
Long-term care