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The Medicaid population can be divided into subgroups based on their relative size and the costs of providing benefits. From the answer choices below, select the response that correctly identifies the subgroups that represent the largest percentages of the total Medicaid population and of total Medicaid expenditures. Largest % of Medicaid Population- Largest % of Medicaid Expenditures-

A.

Largest % of Medicaid Population-dual eligibles Largest % of Medicaid Expenditures-children and low-income adults

B.

Largest % of Medicaid Population-chronically ill or disabled individuals not eligible for MedicareLargest % of Medicaid Expenditures-dual eligibles

C.

Largest % of Medicaid Population-children and low-income adults Largest % of Medicaid Expenditures-chronically ill or disabled individuals not eligible for Medicare

D.

Largest % of Medicaid Population-chronically ill or disabled individuals not eligible for Medicare Largest % of Medicaid Expenditures-children and low-income adults

Selene Varga is participating in her health plan’s disease management program for congestive heart failure. Ms. Varga’s health status is regularly monitored and managed by a licensed nurse who visits Ms. Varga at her home to administer treatment and assess the need for changes in Ms. Varga’s overall care plan. This information indicates that Ms. Varga is participating in the type of disease management program known as a

A.

coordinated outreach model program

B.

case management model program

C.

hub-and-spoke model program

D.

group clinic model program

Many health plans use clinical pathways to help manage the delivery of acute care services to plan members. One true statement about clinical pathways is that they

A.

determine which healthcare services are medically necessary and appropriate for a particular patient in a particular situation

B.

outline the services that will be delivered, the providers responsible for delivering the services, the timing of delivery, the setting in which services are delivered, and the expected outcomes of the interventions

C.

cover only services delivered in an acute inpatient setting

D.

address medical conditions that affect a small segment of a given population and with which the majority of providers are unfamiliar

Determine whether the following statement is true or false:

The key to successfully managing the quality and cost-effectiveness of healthcare services for Medicaid enrollees is to merge Medicaid recipients into existing plans.

A.

True

B.

False

The following statements describe situations in which health plan members have medical problems that require care. Select the statement that describes a situation in which self-care most likely would not be appropriate.

A.

Two days after bruising her leg, Avis Bennet notices that the pain from the bruise has increased and that there are red streaks and swelling around the bruised area.

B.

Calvin Dodd has Type II diabetes and requires blood glucose monitoring tests several times each day.

C.

Caroline Evans has severe arthritis that requires regular exercise and oral medication to reduce pain and help her maintain mobility.

D.

Oscar Gracken is recovering from a heart attack and requires ongoing cardiac rehabilitation.

The following statements are about the use of provider profiling for pharmacy benefits. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

A.

Health plans typically use provider profiles to improve the quality of care associated with the use of prescription drugs.

B.

Provider profiles identify prescribing patterns that fall outside normal ranges.

C.

Health plans can motivate providers to change their prescribing patterns by sharing profile information with plan members and the general public.

D.

Provider profiles are effective in modifying individual prescribing patterns, but they have little effect on group prescribing patterns.

Determine whether the following statement is true or false:

Participation in disease management programs is currently voluntary.

A.

True

B.

False

The following statements are about the use of hospitalists to manage inpatient care. Select the answer choice containing the correct statement.

A.

A patient who has been transferred to a hospitalist for management of inpatient care usually continues to receive care from the hospitalist after discharge.

B.

Hospitalists are used primarily to manage care for obstetric, pediatric, and oncology patients.

C.

In order to serve as a hospitalist, a physician must have a background in critical care medicine.

D.

Hospitalists typically spend at least one-quarter of their time in a hospital setting.

The case management program director at the Nova Health Plan calculated the program’s ratio of medical expense savings to case management administrative costs for the previous quarter based on the following cost information:

Administrative costs for case management ..........$40,000

Actual medical care expenses for patients under case management ..........$680,000

Projected medical care expenses for the same patients without case management ..........$900,000

This information indicates that, for the previous quarter, Nova’s ratio of medical expense savings to case management administrative costs was

A.

0.71/1

B.

0.80/1

C.

5.50/1

D.

1.25/1

The following statements are about risk management for case management. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

A.

The use of a signed consent authorization form is consistent with accrediting agency standards for patient privacy and confidentiality of medical information.

B.

Case management that is initiated after a member has incurred substantial medical expenses is more likely to be viewed as a tool to cut costs rather than to improve outcomes.

C.

Health plan documents indicating that any case management delegates are separate, independent entities may reduce an health plan's exposure to risk.

D.

A case management file cannot be used to support the health plan's position in the event of a lawsuit.