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HSA 312 / HX81:
DECEMBER 22, 2023
MANAGED HEALTH CARE
• PROVIDER PAYMENT AND MANAGING CARE
• PERFORMANCE INDICATORS/QUALITY MEASURES
AND THEIR ROLE IN MANAGING CARE
QUESTIONS TO BE ANSWERED ARE IN
GREEN.
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• QUESTIONS HAVE MULTIPLE PARTS – BRIEFLY ANSWER
EACH PART.
• ANSWERS SHOULD BE SHORT – 3-8 SENTENCES PER
QUESTION AT THE MOST. SOME ANSWERS WILL BE ONE
SENTENCE. SOME WILL BE A SIMPLE YES OR NO.
• SINGLE SPACED.
• 12 POINT TYPE.
• DOWNLOAD THE QUESTIONS FOR THE FINAL, WRITE
ANSWERS UNDER THE QUESTIONS, AND SUBMIT THE
FINAL DOCUMENT VIA THE ASSIGNMENTS PROCESS.
PROVIDER PAYMENT AND MANAGED CARE:
QUESTION 1: TWO KEY APPROACHES TO PAYING PROVIDERS.
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USING ATTACHED
POWERPOINT 11- PART 1 – SLIDES 4,5, 8 AND 9.
POWERPOINT 11 – PART 2 – SLIDES 3-6.
READING 1. PAGES 3, 6, AND 7.
ANSWER THE FOLLOWING:
What is the basic difference BETWEEN Fee-For-Service Payments and
Bundled Payments, which are the two (2) main ways to pay providers for delivering
Personal Health Care Goods and Services? (HINT: How do those terms relate
(respectively) to the restaurant terms A La Carte and Prix Fixe?)
PART A:
PART B: Give ONE (1) positive effect of Fee-For-Service Payment on the behavior of a
clinical provider, and ONE (1) positive effect of a Bundled Payment on the behavior of
one or more clinical providers.
PART C: Give ONE (1) negative effect of Fee-For-Service Payment on the behavior of a
clinical provider, and ONE (1) negative effect of a Bundled Payment on the behavior of
one or more clinical providers.
QUESTION 2: METHODS OF PAYING FOR HOSPITAL SERVICES: TWO
APPROACHES
USING ATTACHED READING 3; READING 4; READING 5, PAGES 1
AND 2. ALSO, POWERPOINT 11 – PART 2, SLIDE 5.
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PER DIEMS: Are Per Diems flat, uniform daily payments for nonphysician hospital services, OR do they take into account a patient’s diagnosis,
comorbidities, and specific treatments?
PART A:
PART B:
DIAGNOSIS RELATED GROUPS:
•Are DRGs a form of Bundled Payment? Why?
•Why do DRG prices vary by patient? What patient characteristics serve as the basis
for DRGs?
PART C: Who is more likely to use DRGs to pay hospitals and Integrated Delivery
Systems for inpatient hospital services? Private commercial insurers, or Medicare?
PART D: Who is more likely to use Per Diems to pay hospitals and Integrated Delivery
Systems for inpatient hospital services: Private commercial insurers, or Medicare?
QUESTION 3: BUNDLED PAYMENTS: BASIC PRINCIPLES; DIAGNOSIS
RELATED GROUP EXAMPLE.
USING ATTACHED POWERPOINT 11 – PART 2, SLIDES 3-6; READING
5. ON DRGS; READING 6 AND READING 6.A. ON BUNDLED
PAYMENTS.
PART A:
DIAGNOSIS RELATED GROUPS (DRGs):
Briefly describe ONE (1) Strength or positive aspect of DRGs as a bundled payment
system for paying for Non – Physician Hospital Services.
PART B:
DIAGNOSIS RELATED GROUPS (DRGs):
Briefly describe ONE (1) Weakness or negative aspect of DRGs as a bundled
payment system for paying for Non – Physician Hospital Services.
PART C: Generally speaking about Bundled Payment Systems: What types of
clinical groups (patients with specific diagnoses, patients receiving certain surgical or
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medical procedures) are the best candidates for creating and using Bundled
Payments? Why are they the best candidates?
BASICS OF PERFORMANCE INDICATORS/QUALITY
MEASURES: USING PERFORMANCE INDICATORS
QUESTION 4: PERFORMANCE INDICATORS – TYPES OF QUALITY
MEASURES
USING ATTACHED POWERPOINT 15, SLIDES 3-4, 14-26.
READING 7.; READING 7.A.
PART A:
What is a Performance Indicator/Quality Measure?
What is the difference between an Outcome Indicator and a Process
Indicator of Performance? (The difference in what each type of indicator measures.)
PART B:
What is ONE (1) key information source for monitoring Performance
Indicators?
PART C:
QUESTION 5: PERFORMANCE INDICATORS – HOW THEY ARE USED.
USING ATTACHED POWERPOINT 15, SLIDES 20, 23 AND 24.
READING 7, PAGE 12.
Briefly describe TWO (2) of the main ways in which Performance Indicators are
used by commercial insurance plans, Medicare, and Medicaid.
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QUESTION 6: PERFORMANCE INDICATORS – THE NCQA AND THE
HEDIS INDICATORS.
USING ATTACHED POWERPOINT 15, SLIDES 3-4, 15, 21.
READING 8.
Briefly describe what the National Committee on Quality Assurance
(NCQA) is and does.
PART A:
PART B:
Briefly: What are the HEDIS Performance Indicators?
PART C:
Give ONE (1) example of a HEDIS Performance Indicator.
QUESTION 7: PAY FOR PERFORMANCE: THE CONCEPT/
RELATIONSHIP TO PERFORMANCE INDICATORS
USING ATTACHED,
POWERPOINT 10 – PART 1, SLIDES 13 AND 14.
READING 9.
ANSWER THE FOLLOWING:
What is basic idea of Pay-for-Performance (P4P)? – In other words, how
is this form of payment expected to positively impact on the behavior of clinical
providers? (Doctors and hospitals, for instance.)
PART A:
PART B: What is the connection between Pay-for-Performance and the collection
and analysis of clinical provider Performance Indicators?
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