Quest Chapter 3

Question 1

What is the difference between HMO”s and EPO’s?

Answer 1

The difference is that EPO’s doesn’t usually require that the primary care providers make referrals to specialists while HMO’s do.

Question 2

What is the greatest drawback of HMO?

Answer 2

The greatest draw back lies in the fact that the enrollee must find a physician within the HMO group for services

Question 3

Distributive Health Care

Answer 3

Medical care has shifted from the hospital into the community because of the advances in medical technology such as mobile units for diagnosing disease and telemedicine.

Question 4

What has changed the healthcare system and created new ways of paying for healthcare?

Answer 4

Distributive Health Care

Question 5

Capitation

Answer 5

Paying the practitioner or hospital a fixed amount for a specific service

Question 6

Medicaid

Answer 6

Aid for the low income citizens or families

Question 7

“Fee for Service”

Answer 7

The provider is financially rewarded for volume rather than quality and cost control (value)

Question 8

In 2014,

Answer 8

Medicare Benefit payments totaled $597 billion; about 25% covered hospital inpatient services, another 25% covered private insurance through the Medicare Advantage Program, (these are the 2 top benefit payments)

Question 9

What is the difference between private and medicare insurance?

Answer 9

Patients on Medicare are entitled to the same benefits and care as those with private insurance. The Main difference is that the government pays the healthcare bills instead of the individual or private private insurance.

Question 10

PPO’s

Answer 10

cover care provided both inside and outside the plan’s provider network

Question 11

What are example for capitation of private insurance?

Answer 11

An example are HMO’s which limit consumers choose to health professionals and hospital that contract with the HMO

Question 12

What is the largest public health insurance program?

Answer 12

The largest program is Medicaid as in 2019 medicaid provided coverage to 1 in 5 American’s

Question 13

What was the first pre-payment plan to cover physicians?

Answer 13

Blue Cross - Blue Shield

Question 14

The first managed care insurance programs were started with HMO’s

Answer 14

Kaiser Permanent in California and Group Heath Cooperative in Washington state.

Question 15

What was the prospective payment bill?

Answer 15

Under which hospitals are paid a set amount for each patient in any of the established disease categories and diagnosis related groups.

Question 16

Managed Care

Answer 16

HMO’s, PPO’s and EPO’s

Question 17

Medicare and Medicaid

Answer 17

government or public health insurance which benefit one in three american’s

Question 18

PPO’s

Answer 18

self chosen specialist and also high premiums and higher deductible and lower capitation

Question 19

HMO’s

Answer 19

specialist through physicians and in the network only, lower premiums lower deductibles and higher capitation

Question 20

Blue Cross

Answer 20

First private hospital insurance plan

Question 21

Medicare

Answer 21

Care for the old which are 65 or above and certain disabled people under 65

Question 22

EPO

Answer 22

Doesn’t require the need of a prescription from primary care physician

Question 23

SCHIP

Answer 23

provide healthcare coverage for low-income children

Question 24

Medicaid

Answer 24

each state sets its own guidelines regarding eligibility and services

Question 25

ACA

Answer 25

affordable care act which is access to private insurance and receive government subsidies

Question 26

Preferred Provider

Answer 26

organization of a group of providers who join together on a contract to deliver medical services

Question 27

What was a traditional reimbursement before ACA?

Answer 27

It was fee-for-service payment for each service at the time of service