HOM 5307

Behavioral change tools include all but which of the following?

Analytics
Termination from the network
Mission clarity
Communications

Termination from the network
Fee-for-service physicians are financially rewarded for good disease management in most environments.
T or F
False
The Managed care backlash resulted in which of the following?
A reduction in HMO membership
New federal and state laws and regulations
Reduced administrative costs
A reduction in HMO membership
New federal and state laws and regulations
Which of the following is a typical complaint providers have about health plan provider profiling?
I get different results using my own data
My patients are sicker than other providers’ patients
The quality and cost measures used are not accurate enough
All the above
The HMO Act of 1973 did contributed to the growth of managed care
T or F
True
Which of the following forms of hospital payment contain no elements of risk sharing by the hospital?
DRGs and MS-DRGs
Per diem
Capitation
Sliding scale FFS
Sliding scale FFS
PSOs, created by the BBA of 1997, proved to be very popular and successful.
T or F
False
In January 2006, what large federal prescription drug program was implemented that offered pharmacy benefits to more than 40 million people at that time and is expected to increase by 30% throughout the next decade?
The Department of Defense TRICOR program
Public Health Service and Indian Health Service
State Medicaid programs
Medicare Part D
Medicare Part D
Managed care is best described as:
A broad and constantly changing array of health plans employers, unions, and other purchasers of care that attempt to manage cost, quality, and access to that care

A broad changing array of health plans employers, unions, and other purchasers of care.

A constantly changing array of unions, and other purchasers of care that attempt to manage cost, quality, and access to that care

A array of health plans employers, unions, and other purchasers of care that attempt to manage cost, quality, and access to that care

A broad and constantly changing array of health plans employers, unions, and other purchasers of care that attempt to manage cost, quality, and access to that care
Consolidation in the payer industry has resulted in most hospitals being unable to obtain adequate rate increases.
T or F
False
Which organization(s) need a Corporate Compliance Officer (CCO)?
Hospitals
Health plans with a Medicare Advantage risk contract
Every organization that provides health care
Hospitals and Health plans with a Medicare Advantage risk contract
Health Plan Employer Data and Information Set is the less widely used set of measures for reporting on managed behavioral health care.
T or F
False
The following term refers to an all-inclusive rate paid by the HMO for both institutional and professional services:
Bundled payment
Per diem
Case rate
Straight DRGs
Bundled payment
The original impetus of HMOs development came from:
Providers seeking patient revenues
Insurance companies
Consumers seeking access to health care
A & C Only
Providers seeking patient revenues and Consumers seeking access to health care
HMOs are licensed as health insurance companies.
True
False
false
Common sources of information that trigger DM include:

Claims
Pharmacy data
Laboratory tests
A & b oNLY

Claims and pharmacy
The GPWW requires the participation of a hospital and the formation of a group practice.
True
False
False
An IDS can be described as a legal entity consisting of more than one type of provider to manage a population’s health care and/or contract with a payer organization.
True
False
True
Claims review is an example of
Concurrent review

Discharge planning

Prospective review

Retrospective review

Retrospective review
UM focuses on telling doctors and hospitals what to do.
True
False
False
The same methodology used to pay a hospital for inpatient care is usually also use to pay for outpatient care.
True
False
False
Electronic prescribing offers which of the following potential outcomes?

Improvement in physician drug formulary prescribing conformance

Reduction in drug interactions and resulting serious adverse effects

Reduction in prescribing and dispensing errors

All the above

Improvement in physician drug formulary prescribing conformance

Reduction in drug interactions and resulting serious adverse effects

Reduction in prescribing and dispensing errors

Approximately What percentage of behavioral care spending is associated with what percentage of patients?

5%

10%

15%

20%

5%
When selecting a hospital during the network development phase, an Health Maintenance Organization considers:

Occupancy rate

Cost of services

Scope of services

All the above

Occupancy rate

Cost of services

Scope of services

Most of the care in disease management systems is delivered in the inpatient setting since the acuity is much greater.
True
False
False
State and federal regulations consistently apply network access standards to:

POS plans

HMOs

Preferred Provider Organization

A & B only

POS plans

HMOs

What specific factors other than diseases commonly affect severity of illness?

Culture

Geographic location

Sex

Age

All the above

Culture

Geographic location

Sex

Age

Which of the following organizations may conduct primary verification of a physician’s credentials?

A PPO

A CVO

An HMO

All the above

A PPO

A CVO

An HMO

Hospital consolidation has been blocked more often than not by the Department of Justice (DOJ) and/or the Federal Trade Commission (FTC).
True
False
False
Direct contracting refers to direct contracts between the HMO and the physicians. Almost all models of HMOs contract directly with physicians.
True
False
False
1. EPOs share similarities with:

PPOs

HMOs

Point of Service

A & B

PPOs

HMOs

Key common characteristics of PPOs include:

Selected provider panels

Negotiated payment rates

Consumer choice &
Utilization management

All the above

Selected provider panels

Negotiated payment rates

Consumer choice &
Utilization management

All three methods used to manage utilization during the course of a hospitalization.
Pre-certification that includes the authorized coverage length of stay
Concurrent, or continued stay, review by UM nurses using evidence-based clinical criteria
Discharge planning prior to admission or at the beginning of the stay
True
False
True
What are the basic ways to compensate open-panel PCPs?

Fee-for-service

Capitation

DRGs

A & B only

Fee-for-service
Which of the following is a method for providing a complete picture of care delivered in all health care settings?

Inpatient DRGs

ICD-9 / ICD-10 codes

Health Maintenance Organizations

Episodes of care

Episodes of care
Costs of noncatastrophic, recurring outpatient care have risen significantly in the past few decades.
True
False
True
What is the common benefit design trend in commercial (employer group sponsored) prescription drug benefits?

Increasing copayment amounts, especially for Tier 2 preferred brand drugs and Tier 3 non-preferred brand drugs.

Increasing use of percent coinsurance, especially for Tier 3 and Tier 4 specialty tiers when available..

Increasing number of consumer-directed health plan designs with higher front-end deductibles.

All the above

Increasing copayment amounts, especially for Tier 2 preferred brand drugs and Tier 3 non-preferred brand drugs.

Increasing use of percent coinsurance, especially for Tier 3 and Tier 4 specialty tiers when available..

Increasing number of consumer-directed health plan designs with higher front-end deductibles.

Why is data analysis an increasingly important health plan function?

Cost increases 2-3 times the consumer price index

Potential for improvements in medical management

Third-party consultants that specialize in data analysis and aggregate data across health plans

All of the above

Cost increases 2-3 times the consumer price index

Potential for improvements in medical management

Third-party consultants that specialize in data analysis and aggregate data across health plans

Nurse-on-call or medical advice programs are considered demand management strategies.
True
False
True
Managed care plans perform onsite reviews of hospitals and ambulatory surgical centers.
True
False
False
Who has final responsibility for all aspects of an independent HMO?

Chief Operating Officer (COO)

Board of Directors

Chief Compliance Officer (CCO)

Chief Executive Officer (CEO)

Board of Directors
PPOs differ from HMOs because they do not accept capitation risk and enrollees who are willing to pay higher cost sharing may access providers that are not in the contracted network.
True
False
True
The integral components of managed care are

Wellness and prevention

Primary care orientation

Utilization management

All of the above

Wellness and prevention

Primary care orientation

Utilization management

The defining feature of a direct contract model is the HMO contracting directly with a hospital to provide acute services to its members.
True
False
False
Board of Directors has final responsibility for all aspects of an independent HMO
True
False
True
Select the one technique for controlling drug benefits costs that MOST health plans and PBMs DO NOT routinely use.

Tiered copayments

Contracting with pharmacies for discounts

Drug formularies

Value-based insurance designs that assign “high-value” drugs to Tier 1 for ALL therapeutic categories.

Value-based insurance designs that assign “high-value” drugs to Tier 1 for ALL therapeutic categories.
Prior to the 1970s, health maintenance organizations (HMOs) were known as:

Point-of-service programs

Referred provider organizations

Prepaid practices

Prepaid group practices

Prepaid group practices
Behavioral health care providers are paid under methodologies similar to those applied to medical/surgical care providers.
True
False
True
Academic detailing refers to:

Personal meetings between a respected clinician and a doctor or a small group of doctors

Requiring inadequate physicians to write out, in detail, what they should be doing

Having medical school professors present detailed studies at CME conferences

Minutely scrubbing the data

The function of the board is governance: overseeing and maintaining final
responsibility for the plan. Final approval authority of corporate bylaws rests with the board as does setting and approving policy. General oversight of the profitability or reserve status rests with the board, as does oversight and approval of significant fiscal events and quality management.
True
False
True
The Balance Budget Act (BBA) of 1997 resulted in a major increase in HMO enrollment
True
False
False
Electronic clinical support systems are important in disease management.
True
False
True
Hospitals purchased physician practices and employed physicians in the 1990s, but will no longer do so.
True
False
False
The least appropriate site for disease management is:

Outreach clinic

Ambulatory care setting

Short Stay clinic

Inpatient setting

Inpatient setting
Capitation is usually defined as:

Fee-for-service including withhold provisions

Stop-loss reinsurance provisions

Prepayment for services on a fixed, per member per month basis

Performance based compensation system

Prepayment for services on a fixed, per member per month basis
Capitation is a physician payment method preferred by many HMOs because it:

Costs are predictable

Is less costly to administer than FFS

Eliminates the FFS incentive to overutilize

All the above

Costs are predictable

Is less costly to administer than FFS

Eliminates the FFS incentive to overutilize

The use of utilization guidelines targets only managed care patients and does not have an impact on the care of non-managed care patients.
True
False
False
Managed prescription drug programs must be flexible and customize pharmacy benefit designs to accommodate diverse financial and benefit richness desires of their customers.
True
False
True
More than 90% of members of employer-sponsored health plans have access to prescription drug coverage, and over 90% of all prescriptions in the U.S. are reimbursed by insured prescription drug benefit programs.
True
False
True
In what model does an HMO contract with more than one group practice provide medical services to its members?

Group model

Staff model

Independent Physician Association model

Network model

Network model
The HMO Act of 1973 did not retard HMO development in the few years after its enactment
True
False
False
Ancillary services are broadly divided into the following categories:

Diagnostic and therapeutic

Pharmacy and radiology

Laboratory and therapeutic

A & C only

Diagnostic and therapeutic
Medical Directors typically have responsibility for:

Utilization management

Benefits determinations for appeals

Quality management

All the above

Utilization management

Benefits determinations for appeals

Quality management

Hospital utilization varies by geographical area.
True
False
True
Recent legislation encourages separate lifetime limits for behavioral care.
True
False
False
A PHO is usually a separate business entity requiring the participation of a hospital and at least some of the hospital’s admitting physicians.
True
False
True
One potential negative consequence of drug formularies with high copayments is:

Decreased use of the most cost-effective medications

Low copayments may be a barrier to adherence

Increased use of brand drugs

High copayments may be a barrier to adherence

High copayments may be a barrier to adherence
In markets with high levels of managed care penetration, hospitals are usually paid using a sliding scale discount on charges method.
True
False
False
Establishing a high level of evidence regarding disease management guidelines ensures:

Validity

Statistical significanc

None of the above

Reliability

Validity
Two desirable outcomes of tiered prescription member copayments are:

Pharmacy gross profits rise and physicians are paid a formulary incentive

Member costs increase and brand name drug use will double

Brand drug use increases and generic drug use declines

The use of less expensive generic drugs increases and members save money by paying lower Tier 1 generic copayments

The use of less expensive generic drugs increases and members save money by paying lower Tier 1 generic copayments
Fee-for-service payment is the most common method used by HMOs to pay specialists.
True
False
True
It is possible for a specialist to also act as a primary care provider.
True
False
True
The majority of prescriptions for behavioral health medications are written by nonpsychiatrists.
True
False
True
Basic elements of credentialing include:

Hospital privileges

Malpractice history

Medical license

Board Exams

All the above

Hospital privileges

Malpractice history

Medical license

Board Exams

Payment to a facility for outpatient procedures may be increased on a case-by-case basis through which of the following?

Outlier
CoPays
Carve-outs
A and B

Carve-outs
Academic detailing refers to:

Requiring inadequate physicians to write out, in detail, what they should be doing

Having medical school professors present detailed studies at CME conferences

Minutely scrubbing the data

Personal meetings between a respected clinician and a doctor or a small group of doctors

Personal meetings between a respected clinician and a doctor or a small group of doctors
Pay for performance (P4P) cannot be applied to behavioral health care providers.
True
False
False
The typical practicing physician has a good understanding of what is happening with his or her patient between office visits
True
False
False
All of the following are alternatives to acute care hospitalization.
▪ Subacute care
▪ Step-down units
▪ Outpatient facilities/units
▪ Home care
▪ Hospice care
True
False
True
Commonly recognized HMOs include:

IPAs

Network

Staff and group

All the above

IPAs
Blue Cross began as a physician service bureau in the 1930s.
True
False
False
Health care cost inflation has remained consistent since 1995.
True
False
False
In the medical management area, committees serve to diffuse some elements of responsibility and allow important input from the field into procedure and policy or even into case-specific interpretation of existing policy.
True
False
True
An IPA is an HMO that contracts directly with physicians and hospitals
True
False
False
Utilization management seeks to reduce practice variation while promoting good outcomes and ___.

Maintaining costs

Increasing patients

Reducing access

None of the above

None of the above
Outbound calls to physicians are an important aspect to most DM programs.
True
False
False
The most common measurement of inpatient utilization is:

Enrollees per thousand bed days

Admissions per thousand bed days

Encounters per thousand enrollees

Bed days per thousand enrollees

Bed days per thousand enrollees
How are outlier cases determined by a hospital?

Through cost-accounting

Through a Resource Based Relative Value Scale

Through the chargemaster

All the above

Through the chargemaster
Which organization(s) accredit managed behavioral health care companies?

National Committee for Quality Assurance

The Joint Commission

Utilization Review Accreditation Commission

Councile of Accreditaion

All the above

National Committee for Quality Assurance

The Joint Commission

Utilization Review Accreditation Commission

Councile of Accreditaion

Considerations for successful network development include geographic accessibility and hospital-related needs.
True
False
True
What technique is used by many pharmaceutical companies with health plans and PBMs to increase formulary access and utilization of specific products?

Rebates for preferred formulary position

Health economic data, including a growing number of head-to-head clinical trials

Member copayment coupons to offset copayment

All the above

Rebates for preferred formulary position

Health economic data, including a growing number of head-to-head clinical trials

Member copayment coupons to offset copayment

What statement is true regarding the trends of traditional, non-specialty drugs (mostly oral and topical drugs dispensed in community pharmacy) and specialty drugs (biotech, injectables, high-cost orals)?

Most plans do not cover specialty drugs, except under the medical benefit,and specialty products, therefore, are of no serious cost consequence to pharmacy benefits. The number of generic drugs is declining due to lower manufacture costs and, as a result, traditional (non-specialty) drug products remain the focus of most of the pharmacy budget increases.

Traditional drug costs are rising rapidly due to continued launch of new, expensive brand drugs, with only a few approved genericas. The specialty market cost trend is declining as a result of biosimilar “generic” injectable products imported from Europe.

Many expensive and popular traditional drugs are losing patent protection, and generics are driving a declining cost trend. A growing number of the drugs in the pipeline for FDA approval are injectable products and the specialty drug trend, already at 20%, is expected to increase.

The cost trends and utilization rates of both types of drugs are increasing by 20% per year or more, although specialty drugs are plateauing.

Many expensive and popular traditional drugs are losing patent protection, and generics are driving a declining cost trend. A growing number of the drugs in the pipeline for FDA approval are injectable products and the specialty drug trend, already at 20%, is expected to increase.
Advantages of an IPA include:

Broader physician choice for members

More convenient geographic access

Requires less start-up capital

All the above

Broader physician choice for members