HPHM 4312 Health Insurance & Managed Care - Midterm Exam Review (Qns & Ans) - TTUHSC 2025, Exams of Nursing

Download HPHM 4312 Health Insurance & Managed Care - Midterm Exam Review (Qns & Ans) - TTUHSC 2025 and more Exams Nursing in PDF only on Docsity!

HPHM 4 31 2 Health Insurance &

Managed Care

Midterm Exam Review

(Questions & Solutions)

1. Multiple Choice Question: A state government is proposing a major reform in Medicaid coverage. As a Healthcare Management professional, you are asked to assess the impact of this reform. Which policy objective is most likely to be prioritized by lawmakers in this context?

• A. Increasing provider reimbursements solely
• B. Enhancing access to care for low‑income populations
• C. Decreasing administrative costs without changing eligibility
• D. Expanding elective services without revising eligibility criteria Correct ANS: B. Enhancing access to care for low‑income populations Rationale: Medicaid reform typically aims to increase access to care for vulnerable groups. Improving eligibility and coverage for low‑income residents is central to achieving better population health and reducing disparities.

---

2. Fill-in-the-Blank Question: The framework used to assess the external environment—including Political, Economic, Social, Technological, Environmental, and Legal factors—is known as __________ analysis. Correct ANS: PESTEL Rationale: PESTEL analysis is a strategic tool used to identify and monitor external factors that may impact the organization’s performance. In healthcare

reimbursement structures, legal frameworks, quality initiatives, and alignment with the organization’s mission. Focusing solely on internal IT (D) overlooks broader policy and strategic issues.

---

5. Multiple Choice Question: In the context of value‑based care, which component of the Triple Aim framework guides healthcare systems to improve population health outcomes?

• A. Enhancing patient experience
• B. Reducing per capita cost
• C. Improving population health
• D. Increasing service volume Correct ANS: C. Improving population health Rationale: The Triple Aim focuses on enhancing patient experience, reducing costs, and improving health outcomes for populations. Emphasizing population health is key to reducing disparities and developing sustainable care strategies.

---

6. Fill-in-the-Blank Question: A policy that outlines what services a health plan will cover and what benefits are available to enrollees is known as the __________ package. Correct ANS: benefit

Rationale: The benefit package is a critical component of health insurance policy. It details covered services, eligibility criteria, and limits, guiding both patient expectations and insurer reimbursement.

---

7. True/False Question: True or False: Health systems management requires a continual balance between cost containment and quality improvement to avoid compromising patient care. Correct ANS: True Rationale: Successful health systems management strategically manages limited resources while striving to maintain and enhance quality care, thereby ensuring both fiscal responsibility and positive patient outcomes.

---

8. Multiple Response Question: Which external factors are major drivers of changes in health systems policy? (Select all that apply)

• A. Technological advancements
• B. Economic conditions
• C. Demographic shifts
• D. Political and legislative changes
• E. Internal staff scheduling practices Correct ANSs: A, B, C, D

Correct ANS: SWOT Rationale: SWOT analysis is a standard tool that helps healthcare managers understand their internal capabilities and external conditions, forming the basis for strategic initiatives and policy decisions.

---

11. True/False Question: True or False: Evidence-based management practices require that healthcare strategies be continually updated based on the latest research findings and clinical outcomes data. Correct ANS: True Rationale: Evidence-based management integrates data, research, and clinical outcomes to guide improvements. Continuous updates ensure strategies remain effective and responsive to new challenges and innovations.

---

12. Multiple Response Question: Which of the following are common revenue sources for healthcare organizations under managed care? (Select all that apply)

• A. Medicare reimbursements
• B. Medicaid reimbursements
• C. Private insurance payments
• D. Out-of-pocket payments
• E. Investment returns from unrelated industries

Correct ANSs: A, B, C, D Rationale: Revenue for managed care organizations is typically derived from government programs (Medicare/Medicaid), private insurers, and patient payments. Investment returns (E) are not considered a primary healthcare revenue source.

---

13. Multiple Choice Question: A managed care organization (MCO) intends to implement a new value- based payment model. Which approach shifts financial risk from the payer to the provider by offering a fixed payment per patient?

• A. Fee-for-service
• B. Bundled payments
• C. Capitation
• D. Shared savings Correct ANS: C. Capitation Rationale: Capitation entails providers receiving a set fee per patient over a defined period, irrespective of the number of services provided. This model incentivizes efficiency and preventive care.

---

14. Fill-in-the-Blank Question: Health systems that focus on achieving improved clinical outcomes while

• B. Internal Rate of Return (IRR) calculation
• C. Sensitivity analysis
• D. SWOT analysis
• E. Break-even analysis Correct ANSs: A, B, C, E Rationale: NPV, IRR, sensitivity, and break-even analyses offer quantitative measures to evaluate investments and forecast financial performance. SWOT analysis (D) is more strategic than strictly financial.

---

17. Multiple Choice Question: 

To assess healthcare quality improvements within a health system, which performance measurement framework focuses on both clinical and financial outcomes?

• A. Balanced Scorecard
• B. SWOT analysis
• C. Kaizen approach
• D. PESTEL analysis Correct ANS: A. Balanced Scorecard Rationale: The Balanced Scorecard provides a multi-dimensional approach to performance measurement including financial, customer, internal process, and learning and growth perspectives, crucial in evaluating comprehensive quality outcomes in healthcare.

---

18. Fill-in-the-Blank Question: The ongoing process of scanning the external environment for emerging trends, regulatory changes, and market dynamics is known as __________ scanning. Correct ANS: environmental Rationale: Environmental scanning is essential for healthcare organizations to anticipate external shifts and adapt strategies accordingly. It provides a basis for strategic planning and risk management.

---

19. True/False Question: True or False: Health systems management integrates internal clinical quality with external market pressures to design policies that optimize both care delivery and cost efficiency. Correct ANS: True Rationale: Effective health systems management must reconcile internal quality improvement goals with external market and regulatory demands. This integrated approach ensures that policies deliver high-quality care while maintaining fiscal responsibility.

---

20. Multiple Response

organizations to achieve economies of scale and improve efficiency. This approach consolidates market presence and reduces redundancy in services.

---

22. Fill-in-the-Blank Question: A __________ framework helps healthcare leaders assess the internal and external factors that affect an organization’s strategy by mapping strengths, weaknesses, opportunities, and threats. Correct ANS: SWOT Rationale: The SWOT framework is an essential strategic planning tool, providing insights into internal capabilities (strengths and weaknesses) and external environments (opportunities and threats), guiding informed policy and management decisions.

---

23. True/False Question: True or False: Pay-for-performance models in healthcare incentivize providers to improve quality by linking reimbursement to specific performance metrics. Correct ANS: True Rationale: Pay-for-performance ties financial incentives directly to quality outcomes, aligning provider reimbursement with the achievement of

targeted care benchmarks and improved patient outcomes.

24. Multiple Response Question: Which strategic planning tools are most useful for evaluating an organization’s readiness to adopt new policy initiatives? (Select all that apply)

• A. PESTEL analysis
• B. SWOT analysis
• C. Gap analysis
• D. Pareto analysis
• E. Stakeholder mapping Correct ANSs: A, B, C, E Rationale: Tools like PESTEL, SWOT, gap analysis, and stakeholder mapping help leaders assess the external environment, internal capabilities, and stakeholder expectations, forming the basis for effective policy implementation. Pareto analysis (D) is typically used for prioritizing problems rather than for overall readiness assessment.

---

25. Multiple Choice Question: A healthcare manager is using the Net Present Value (NPV) method to evaluate a new technology investment. What does a positive NPV indicate?

• A. The project is expected to generate returns greater than the cost of capital
• B. The technology will only break even

Correct ANS: True Rationale: Fee-for-service models reward providers based on the number of services rendered rather than on quality outcomes, which can encourage higher volumes of procedures without necessarily improving care quality.

---

28. Multiple Response Question: Which strategies are used by healthcare organizations to improve operational efficiency and enhance cost control? (Select all that apply)

• A. Implementing Lean and Six Sigma methodologies
• B. Establishing integrated delivery networks (IDNs)
• C. Utilizing electronic health records to streamline operations
• D. Ignoring waste reduction in operational processes
• E. Adopting value-based care reimbursement models Correct ANSs: A, B, C, E Rationale: Lean and Six Sigma, IDN formation, EHR implementation, and value- based reimbursement models all promote efficiency and cost control. Ignoring waste reduction (D) runs contrary to these goals.

---

29. Multiple Choice Question: A healthcare management team is considering the impact of new federal regulations on reimbursement rates. Which administrative strategy is most effective in preparing for these changes?

• A. Ignoring the upcoming regulation to avoid disruption
• B. Engaging in proactive financial reforecasting and scenario planning
• C. Delaying all policy updates until regulations are finalized
• D. Solely increasing patient fees to offset potential losses Correct ANS: B. Engaging in proactive financial reforecasting and scenario planning Rationale: Proactive financial reforecasting and scenario planning allow organizations to anticipate regulatory shifts and adapt strategies accordingly while minimizing adverse impacts on operations and patient care.

---

30. Fill-in-the-Blank Question: 

A comprehensive __________ evaluation in health systems policy management measures an initiative’s overall effect on patient care outcomes, service efficiency, and financial performance. Correct ANS: impact Rationale: An impact evaluation synthesizes qualitative and quantitative data to determine whether a policy or initiative meets its objectives, thereby guiding continuous quality improvement and strategic decision-making. What is the primary purpose of managed care organizations (MCOs)? A) To increase healthcare costs B) To improve the quality of healthcare while reducing costs C) To eliminate all healthcare providers D) To provide unlimited access to specialists

C) American Medical Association (AMA) D) World Health Organization (WHO) Correct ANS: B Rationale: CMS is responsible for administering the nation’s major healthcare programs, including Medicare and Medicaid. True/False: The Affordable Care Act (ACA) eliminated lifetime and annual limits on essential health benefits in most health plans. Correct ANS: True Rationale: The ACA prohibits lifetime and annual limits on essential health services, ensuring greater coverage for patients. Fill-in-the-Blank: __ is the term used for the process of evaluating the necessity and efficiency of healthcare services and procedures. Correct ANS: Utilization Management Rationale: Utilization management involves assessing healthcare services to ensure they are necessary and appropriate. Multiple Choice: What is the main focus of value-based care models in health insurance? A) Volume of services provided B) Cost reduction only C) Patient outcomes and quality of care D) Provider income maximization Correct ANS: C Rationale: Value-based care emphasizes improving patient outcomes and quality while efficiently managing costs. Multiple Response: Which of the following are benefits of using Electronic Health Records (EHRs) in managed care? (Select all that apply) A) Improved patient data accessibility B) Increased administrative costs

C) Enhanced care coordination D) Reduced medication errors Correct ANSs: A, C, D Rationale: EHRs improve data sharing, care coordination, and can reduce errors, contributing to better patient care. True/False: The term "underwriting" in health insurance refers to the process of assessing the risk of insuring a potential policyholder. Correct ANS: True Rationale: Underwriting evaluates the risk associated with applicants to determine eligibility and premium rates. Fill-in-the-Blank: __ is a system where consumers are encouraged to take charge of their healthcare decisions to promote better health outcomes and cost savings. Correct ANS: Consumer-Driven Health Care Rationale: This approach empowers patients to make informed healthcare choices, often leading to improved outcomes and reduced costs. Multiple Choice: Which of the following best describes a high-deductible health plan (HDHP)? A) A plan with low premiums and low out-of-pocket costs B) A plan with high premiums and low deductibles C) A plan that requires high out-of-pocket expenses before coverage kicks in D) A plan that covers only preventive services Correct ANS: C Rationale: HDHPs typically have higher deductibles that must be met before insurance coverage starts, but often have lower premiums. Multiple Response: