PUBHLTH 1 Lecture Notes - Lecture 63: Preferred Provider Organization, Coronary Artery Bypass Surgery, Health Maintenance Organization

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mauvemole377

28 Mar 2019

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Price controls - limit new facilities and technology. Managed care - when you bargain with providers, doctors, and hospitals for discounts. Ppos (preferred provider organization) - patients must seek care from participating providers. Participating providers agree to provide services at lower rates. Hmos (health maintenance organization) - acts as insurer and provider. Agrees to provide all required for a fix payment. Incentives to limit access to specialist and technology. Oregon experiment - w/ medicaid (goal to cover all citizens whose incomes below poverty level, medical necessities. State developed a list of services using town meetings and public hearings: criteria includes life expectancy, quality of life, cost effectiveness, likely number of people who would benefit. 27 health services research (chapter 28 in the 4th edition) Small area analysis - large variations in practice style by geographical area. More variation for conditions on which evidence for appropriate therapy exists. Sometimes more than one therapy may be appropriate.

Related Questions

If an insurer incorrectly estimates an insured person'spremium

, then the insurer will suffer a financial loss.

can appeal to the state insurance commissioner for asubsidy.

will drop people whose medical expenses exceed theirpremium.

None of the above

Medicare Part B (physician and outpatient services) is financedby

a premium that is 75 percent subsidized by the government and 25percent subsidized by the aged.

a payroll tax on both the employee and the employer.

a premium that is 100 percent subsidized by the government.

both a subsidized premium and a payroll tax

The diagnosis-related group hospital payment system changedhospital incentives by making it more profitable to

employ physicians.

admit sicker Medicare patients.

reduce a patient's length of stay.

charge more for lab tests.

Medicare is difficult to reform because

		pharmaceutical manufacturers benefit from drug sales under PartD.
		senior congressional leaders do not want their Medicare benefitschanged.
		the Medicare population is opposed and have highvoting-participation rates.
		Medicare reform would likely increase the federal deficit.

Medicare is not considered to be a fair redistributive systembecause

Medicare beneficiaries receive large subsidies regardless of howhigh their income is.

low-income Medicare beneficiaries with high out-of-pocketexpenses must enroll in Medicaid.

low-income employees subsidize high-income Medicarebeneficiaries.

All of the above

Substituting an income-related voucher for the current Medicaidsystem would not achieve the following:

		An income-related voucher would eliminate the large differencesbetween states in the percentage of their populations eligible forMedicaid.
		An income-related voucher would reinforce the movement towardMedicaid managed care, with its emphasis on coordinated care andincentives to provide care in less costly settings.
		An income-related voucher would provide employees with anincentive to forego higher pay so that they qualify for the vouchersubsidy.
		An income-related voucher would provide those on Medicaid withan incentive to take higher-paying jobs because they would onlylose part of their voucher subsidy.

Most states have shifted their Medicaid beneficiaries intoprivate Medicaid managed care/HMO plans. What is the advantage tothe state for doing so?

		Medicaid patients are more likely to receive coordinated careand preventive services.
		By paying HMOs a fixed fee per person per month, states are ableto shift their risk for higher expenditures to a managed careplan.
		Medicaid patients are more likely to have access to a physicianwithin the HMO.
		The HMOs have entered the Medicaid market because they believethey can provide the care less expensively and earn a profit.

What are some legitimate ways to spend down one's assets toqualify for Medicaid?

Fixing up one's house, purchasing a new car, or setting up aspecial burial account

Providing financial gifts to one's children

Transferring property to one's children

Setting up special retirement accounts that can be passed on tochildren or relatives after seven years

How is Medicaid administered?

		By each state, but policy is shared with the federalgovernment
		By the federal government and coordinated with the states
		By a joint commission composed of federal and stateappointees
		None of the above

Why were hospitals and physicians willing to participate in anHMO's provider network?

Hospitals and physicians developed excess capacity and werewilling to discount their prices for more patients.

Hospitals and physicians believed that they could reduce medicalcosts by joining together to better manage patient care.

Some states provided hospitals and their employed physicians anincentive to join or start HMOs to serve their Medicaidpatients.

b and c

How did early managed care firms achieve their largestsavings?

		By limiting access to very expensive specialty prescriptiondrugs
		By reducing hospital utilization of its enrollees
		By making enrollees wait long periods to see their primary carephysician
		By limiting enrollees' access to the HMO's specialists

Managed care plans differ according to the restrictiveness oftheir provider network and access to specialists. Which types ofplans are likely to have the lowest premiums?

		Plans that have the largest ratio of primary care physicians tospecialists
		Plans that have the most experience and have been in existencethe longest
		Plans that have the most restrictive/narrow provider network
		Plans that have received the highest quality and outcomemeasures

QUESTION 20

As part of the Affordable Care Act, health insurance exchangeswere established. What have been the most importantcost-containment approaches used by health plans competing forinsurance exchange enrollees?

		Health plans have used very narrow/limited providernetworks.
		Health plans have dramatically reduced access to new medicaltechnology.
		Health plans have included large deductibles and out-of-pocketpayments.
		a and c

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PUBHLTH 1 Lecture Notes - Lecture 63: Preferred Provider Organization, Coronary Artery Bypass Surgery, Health Maintenance Organization

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