HSM420 FINAL EXAM FULLY SOLVED - 22641

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Multiple choice


(TCO 1) The original impetus of HMOs development came from _____. (Points : 5)
       providers seeking patient revenues
       consumers seeking access to health care
       employers
       All of the above
       None of the above

2. (TCO 2) Capitation is usually defined as _____. (Points : 5)
       prepayment for services on a fixed, per member, per month basis
       fee for service including withhold provisions
       performance-based compensation system
       stop-loss reinsurance provisions
       None of the above

3. (TCO 3) To determine the appropriate capitation payment for a PCP, a plan would most commonly consider _____. (Points : 5)
       scope of covered service
       age and gender of enrolled members
       current health status of members
       A and B only
       All of the above

4. (TCO 3) Reimbursement of physicians in an HMO model is typically on the basis of _____.
(Points : 5)
       fee-for-service
       fee schedule
       capitation
       POS

5. (TCO 4) The first step in developing a quality management program is to _____. (Points : 5)
       develop measures to screen diseases
       identify process criteria
       understand consumer need
       None of the above

6. (TCO 4) Which of the following regulation requires HMOs to have an internal system that identifies
opportunities to improve care, measure the performance of participating providers, and conducting peer
review activities? (Points : 5)
       Utilization Review Model Act
       Health Care Professional Credentialing Verification Model Act
       NAIC Quality Assessment and Improvement Model Act
       None of the above

7. (TCO 5) In terms of sales, the basic product of a Managed Care Organization is _____.
(Points : 5)
       a delivery system that brings together several components to offer consumers high-quality medical services at affordable prices
       a network to increase business volume
       expanded referrals to the practice
       effective coding, billing, and collection services

8. (TCO 7) Information disclosure, confidentiality of health care information and access to emergency
medical services are key provisions of the _____.
(Points : 5)
       NCQA code
       Hippocratic Oath
       Patient Bill of Rights
       JCAHO Code of Ethics


 
SHORT ANSWER TYPE QUESTIONS


 

1.      1. Briefly explain how the HMO Act of 1973 contributed to the growth of managed care. (Points : 10)

 

2.      2. What are some methods used in managed care for reducing costs and/or increasing quality of care? (Points : 10)

 

3.     3.  Why is it generally believed that there will always be conflict in the U.S. healthcare delivery system? (Points : 10)

 

4.      4. What is the role of healthcare managers in the future of managed care? (Points : 10)

 

5.     5.  Briefly explain the difference between the terms community rating and experience rating. (Points : 10)

 

6.      6. Describe prospecting as it relates to the MCO sales process. (Points : 10)

 

7.      7. Develop a case study of a patient with chronic diseases (that is, take the patient on a journey from start to finish) through the various systems. Given the situation you have described (the problem), what should you do in regard to the following elements of care: disease management, care management, and case management? (Points : 10)

 

8.     8.  Explain the role of the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) relative to managed care organizations. What does JCAHO do for healthcare firms? (Points : 10)

 



ESSAY QUESTIONS

 

 

 

1.    What are some of the key provisions of HIPAA? How has this law impacted healthcare? (Points : 20)

 

2.      List four reasons for creating an authorization system. Which do you consider the most important driving reason? (Points : 20)

 

3.      If we could ever achieve a perfect world of fully integrated medical care, how would each clinical decision be made? (Points : 20)

 

4.      Continuing challenges in U.S. healthcare, regardless of healthcare reform, can be expected for a variety of reasons. What are some of the major reasons why healthcare will continue to be a challenging industry to manage? (Points : 20)

 

5.      Judge the impact of managed care on the affordability and quality of healthcare. (Points : 20)

 

6.      Are there advantages of capitation from a primary care doctor’s perspective? If so, what are the advantages? (Points : 20)

 

7.      Managed care markets go through various stages as you have learned. What type of marketing strategy might work well in a Stage Four market? (Points : 20)

 

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