Ch 6 Health Care Systems

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What is the central role of health services financing in the US
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Fund health insurance
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What is the primary mechanism that enables people to obtain health services
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health insurance
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the phenomenon called moral hazard results directly from
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health insurance coverage
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liberal reimbursement for a given technology will ____ innovation/diffusion of that technology
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increase
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controlling total health care expenditures by restricting financing for health insurance
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Demand side rationing
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in national health care systems total expenditures are controlled mainly by
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supply side rationing
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national health expenditures E =
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E = P x Q
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in general sense what is primary purpose of insurance
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protection against risk
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private health insurance is also called
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voluntary insurance
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under community rating
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both high and low risk people are charged the same premium
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which method of risk assessment is required by ACA for individual and small group health insurance
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adjusted community rating
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under experience rating
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favorable risk groups pay a lower premium than high risk
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what is the main advantage of group insurance
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risk is spread out among a large number of insured
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self insurance was spurred by
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government policy
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the employee retirement income security act
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exempts self insured plans from certain mandatory benefits
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cost is shifted from people in poor health to the healthy when
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premiums are based on community rating
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health insurance pays for medical care after insured pays first 1000
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deductible
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copayment is generally paied
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each time the insured revives health care services
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what was the main conclusion of the rand health insurance experiment
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cost sharing lowered health care utilization without any significant health consequences
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medical policies are sold by
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private insurance companies
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the ACA specifies that ____ can be covered under parents insurance plans
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children under 26
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how are preexisting medical conditions covered under the ACA
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private insurance plans have to cover them starting 2014
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under ACA what purpose do the exchanges serve
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they allow individuals and small businesses to purchase health plans
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in general how do bronze, silver and gold health plans differ
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they differ according to cost sharing
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what criterion does ACA use to classify an employer as a large employer
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50 or more full time employees
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to purchase private insurance through an exchange premium subsidies are made available to people with incomes up to
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400% federal poverty line
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majority of beneficiaries reviving health care through medicare are
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elderly
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main function of Medicare payment advisory commission MedPAC
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advise the US congress on carious issues affecting the medicare program
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to finance medicare part A
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all income earned by a working person is subject to medicare tax
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skilled nursing care is covered under _____ of medicare
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part A
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the HI portion of medicare is financed through
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payroll taxes
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for medicare beneficiaries the max stay in an SNF during a benefit period cannot exceed
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100 days
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for hospitalizations medicare beneficiaries must pay a deductible
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once per benefit period
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Medicare part B premiums are
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income-based
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SMI provides
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physicians services
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Part C of medicare specifially covers
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–> NONE OF THE FOLLOWING rehab services; preventative care; prescription drugs
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why was medicare part C created
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to channel beneficiaries into managed care programs
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the donut hole in medicare prescription drug coverage
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provides no benefits until the beneficiary qualifies for the catastrophic level
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the SMI trust fund is for
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parts B an D
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the primary criterion to become eligible for medicaid
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financial status
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by law federal matching funds to the states for medicaid cannot be less than
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50%
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the insurance arm of military health care is called
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tricare
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to receive payment for services delivered providers must file a ___ with third party payers
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claim
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the use of fee for service reimbursement
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has been greatly reduced
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_____ reimbursement is based on the assumption that health care is provided in a set of identifiable and individually distinct units of service
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fee for servce
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what is the incentive under fee for service reimbursement
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providers have an incentive to deliver nonessential services
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in general prospective payment systems establish reimbursement for
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bundled services
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RVU’s reflect
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resource inputs
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preferred providers are paid
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negotiated discounted fees
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when a fixed monthly fee per enrollee is paid to a provider its called
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capitation
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capitation removes the incentive to
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provide unnecessary services
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under retrospective reimbursement a health care organization is paid according to
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the costs incurred in operating the institution
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wheat perverse incentive is present in retrospective reimbursement
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providers can increase their profits by increasing costs
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the amount of reimbursement is determined before the services are delivered
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prospective reimbursement
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what is not a type of prospective reimbursement methodology
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cost-plus
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a DRG represents
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a group of principal diagnoses
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an MS-DRG method of reimbursement an acute care hospital is paied
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a fixed amount for a particular DRG classification
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under the DRG method of reimbursement a psychiatric hospital is paid
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a per diem rate based on psychiatric DRG’s
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how is case mix determined for an inpatient facility
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a comprehensive assessment of each patient is done
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what is the minimum data set (MDS)
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a patient assessment instrument for skilled nursing facilities
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if national health expenditures amount to 18% of the GDP
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health care consumes 18% of the total economic production
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the largest share of national health expenditures is attributed to
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personal health care
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public/government share of the total health care spending in the US is approximately
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45%
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adverse selection makes health insurance less affordable for
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those in good health
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Medicaid recipients are classified as medically uninsured t/f
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FALSE
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Health insurance increases the demand for heath care services t/f
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true
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tax policy in the us provides an incentive to obtain employer based health insurance t/f
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true
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people in older age groups represent a higher risk than those in lower age groups t/f
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true
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under community rating people are charged in the same regardless of health risk t/f
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true
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today the majority of health insurance exists in the form of managed care plans t/f
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true
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by law a health insurance plan must cover work related injuries t/f
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false
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the government plays a significant role in financing health care services in the united states t/f
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true
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it is illegal for an insurance company to sell a medical plan to someone who is covered by medicaid t/f
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true
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under the ACA private health insurance will no longer be the main source of coverage t/f
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false
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the ACA requires that employers provide health insurance to part time workers if the employer has 50+ woerks
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false
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health insurance plans are prohibited from having lifetime dollar limits on medical benefits t/f
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true
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health insurance plans are allowed to have annual dollar limits on a persons medical benefit t/f
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false
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undr medicare program, eligibility criteria and benefits are consistent throughout the US t/f
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true
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part D of medicare does not require the payment of a premium t/f
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false
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long term care services for the elderly are covered under medicare
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false
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under the medicaid program eligibility criteria and benefits are consistent throughout the us t/f
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false
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state governments are required to partially finance the medicaid program t/f
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true
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according to a US supreme court decision individual states can decide whether or not to expand their medicaid programs to comply with ACA
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true
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research shows that prospectively set bundled payment methods are effective in reducing health care t/f
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true

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