spierrev
1. Question 1 To identify and adjust for individuals who have…
1.
Question 1
To identify and adjust for individuals who have chronic conditions and other factors that lead to higher than average costs, actuaries have developed risk scores that are calculated using complex algorithms to analyze which of the following variables:
1 point
Demographics
Age
Gender
Health conditions
2.
Question 2
Why have risk adjustment program become critical?
1 point
Risk adjustment programs have become critical to ensuring that patients do not take unnecessary risks.
Risk adjustment programs have become critical to ensuring that payers are able to cover the costs of both healthier enrollees and enrollees with chronic conditions who are a higher risk.
Risk adjustment programs have become critical to ensuring that risky surgeries are prevented.
Risk adjustment programs have become critical to ensuring that insurance companies do not pay for unnecessary risks.
3.
Question 3
What is one goal of risk adjustment?
1 point
To submit accurate and complete information for purposes of appropriate reimbursement.
To adjust the hospitalization risks for patients.
To standardize the risks for underage patients.
To investigate the source of risks for patients who have chronic conditions.
4.
Question 4
Of the following statements about the Medicare Advantage Star Rating Program, check ALL that are true.
1 point
Once a Medicare Advantage plan receives a 5-star rating, it never changes.
The Star Rating Program is the largest value-based care and payment program in the U.S.
The Star Rating Program is a system to assess the quality of care for Medicare Advantage enrollees, while also reducing the rate of increase in federal healthcare expenditures.
The rating provides consumers an “apples to apples” comparison as they research various Medicare Advantage plans.
CMS assigns a 1- to 5-star performance rating to all Medicare Advantage plans; the higher the rating, the better the performance reported for the plan.
5.
Question 5
A fee-for-service payment arrangement that includes an annual bonus payment based on achievement of specific HEDIS quality measures is considered what type of category in a value-based payment arrangement?
1 point
Category 1
Category 2
Category 3
Category 4
6.
Question 6
Which one of the following is an appropriate measure to include in a value-based payment arrangement?
1 point
Patient satisfaction
Patient income
Provider’s credentials
Provider’s office staff
7.
Question 7
Dr. Smith is a primary care physician who has an agreement with ABC Insurance Co.’s Medicare Advantage plan. He is paid a monthly capitation for each member enrolled in his patient panel from ABC Insurance Co. In addition, he receives a share of the savings based on the total cost of care for all patients in his panel. The percentage of the savings he receives is adjusted based on the HEDIS and CAHPS scores of his panel. What category of APM/value-based care arrangement would this be considered?
1 point
Category 4: Population-based payment where payment is not directly triggered by service delivery, so payment is not linked to volume.
Category 3: APM built on fee-for-service architecture. Some payment is linked to the effective management of a segment of the population. Payments are still triggered by the delivery of services, but there are opportunities for shared savings.
Category 2: Fee-for-service with linkage to quality and value. A portion of payments varies based on the quality or efficiency of healthcare delivery.
Category 1: Fee-for-service with no link to quality and value. Payments are based on the volume of services and not linked to quality or efficiency.
8.
Question 8
Dr. Brown is an orthopedic surgeon who is paid a flat rate/bundled payment for each knee replacement surgery she performs. She believes that her patients’ length of hospital stays and complication rates for these procedures are better than her peers. She also believes the final clinical outcome is dependent on the hospital, the physical therapist, and the patient’s willingness to do the necessary rehab, so she will not agree to any adjustment to her payment based on quality or patient satisfaction metrics. She does potentially receive additional compensation based on the total cost of care for each episode if, collectively, they are below targeted costs. Is this a value-based arrangement?
1 point
Yes, it is a value-based arrangement.
No, it is not a value-based arrangement.
9.
Question 9
Dr. Jones is a primary care physician who is paid a monthly capitation and receives a share of the savings based purely on the costs of his patient panel. Is this a value-based arrangement?
1 point
Yes, it is a value-based arrangement.
No, it is not a value-based arrangement.
10.
Question 10
Which term describes the method CMS uses to ensure that payments to health plans reflect the health status and risk of enrollees in a covered population?
1 point
Health assessment
Risk adjustment
Enrollee adjustment
Health risk
