#1
What is the primary goal of managed care in healthcare?
To improve quality of care while controlling costs
ExplanationBalancing quality improvement and cost control in healthcare.
#2
Which of the following is a key feature of a Health Maintenance Organization (HMO)?
Requirement of referrals for specialists
ExplanationHMOs require referrals for patients to see specialists.
#3
Which of the following is a potential disadvantage of managed care for patients?
Limited choice of healthcare providers
ExplanationManaged care may limit the choice of healthcare providers for patients.
#4
Which of the following is a characteristic of a Preferred Provider Organization (PPO)?
Ability to see out-of-network providers at a higher cost
ExplanationPPOs allow seeing out-of-network providers at a higher cost.
#5
What is a characteristic feature of a Point of Service (POS) plan?
Freedom to see out-of-network providers without penalty
ExplanationPOS plans offer the freedom to see out-of-network providers without penalty.
#6
Which of the following is NOT a characteristic of managed care organizations (MCOs)?
Unrestricted access to any healthcare provider
ExplanationManaged care organizations do not offer unrestricted access to all healthcare providers.
#7
In managed care, what does the term 'gatekeeper' refer to?
The primary care physician who coordinates a patient's care and referrals
ExplanationThe gatekeeper is the primary care physician responsible for coordinating patient care and referrals.
#8
Which act played a significant role in the expansion of managed care in the United States?
Health Maintenance Organization Act of 1973
ExplanationThe Health Maintenance Organization Act of 1973 played a key role in the expansion of managed care in the U.S.
#9
What is the role of a pharmacy benefit manager (PBM) in managed care?
To negotiate drug prices with pharmaceutical companies
ExplanationPBMs negotiate drug prices with pharmaceutical companies in managed care.
#10
What is adverse selection in the context of managed care?
The tendency for healthier individuals to enroll in managed care plans
ExplanationAdverse selection is the tendency for healthier individuals to enroll in managed care plans.
#11
What is the main principle behind utilization management in managed care?
To ensure patients receive appropriate care at the right time and cost
ExplanationUtilization management aims to ensure appropriate care timing and cost for patients.
#12
What is the primary objective of disease management programs in managed care?
To control healthcare costs related to chronic conditions
ExplanationDisease management programs aim to control costs related to chronic conditions in managed care.
#13
What is the primary focus of managed care accreditation organizations?
Evaluating compliance with healthcare regulations
ExplanationAccreditation organizations focus on evaluating compliance with healthcare regulations in managed care.
#14
What is the primary focus of a Health Information Management (HIM) department in a managed care organization?
Ensuring data security and integrity of medical records
ExplanationHIM departments focus on ensuring data security and integrity of medical records in managed care.
#15
What is a common method used by managed care organizations to control healthcare costs?
Utilizing prior authorization for certain treatments
ExplanationPrior authorization for certain treatments is a common method to control healthcare costs in managed care.