ABPS Healthcare Systems & Administration 3 — Questions and Answers
Question 1: What is the primary goal of a Health Maintenance Organization (HMO)?
- Providing unlimited specialist access without referrals
- Coordinating care through a primary care gatekeeper to manage costs (Correct answer)
- Reimbursing all out-of-network providers at full rates
- Eliminating co-payments for all preventive services
Correct answer: Coordinating care through a primary care gatekeeper to manage costs
HMOs use a primary care physician as a gatekeeper to coordinate care, reduce unnecessary services, and control costs within a defined network.
Question 2: Which of the following best describes 'never events' in healthcare?
- Rare diagnostic errors that cannot be prevented
- Serious, largely preventable adverse events that should never occur in a hospital (Correct answer)
- Unforeseen complications from experimental treatments
- Patient deaths attributable to natural disease progression
Correct answer: Serious, largely preventable adverse events that should never occur in a hospital
Never events are serious, preventable patient safety incidents — such as wrong-site surgery — that CMS considers unacceptable and does not reimburse.
Question 3: The 'triple aim' framework in healthcare improvement refers to simultaneously pursuing:
- Cost reduction, revenue growth, and staff satisfaction
- Better patient experience, improved population health, and reduced per capita cost (Correct answer)
- Quality metrics, safety standards, and regulatory compliance
- Access to care, clinical research, and workforce development
Correct answer: Better patient experience, improved population health, and reduced per capita cost
Developed by the Institute for Healthcare Improvement, the Triple Aim targets improved individual experience, better population health outcomes, and lower per capita costs.
Question 4: Under HIPAA, a 'covered entity' includes which of the following?
- Pharmaceutical sales representatives
- Health plans, healthcare clearinghouses, and healthcare providers who transmit health information electronically (Correct answer)
- Medical device manufacturers only
- Hospital construction contractors
Correct answer: Health plans, healthcare clearinghouses, and healthcare providers who transmit health information electronically
HIPAA's covered entities are health plans, healthcare clearinghouses, and providers that conduct standard electronic transactions, all subject to privacy and security rules.
Question 5: An Accountable Care Organization (ACO) holds providers accountable for:
- Maximizing the number of procedures performed per patient
- The quality and total cost of care for an assigned patient population (Correct answer)
- Ensuring all patients are enrolled in government insurance programs
- Reducing hospital readmissions to zero within 30 days
Correct answer: The quality and total cost of care for an assigned patient population
ACOs are groups of providers who coordinate care for a defined population and share in savings (or losses) relative to a spending benchmark, linking payment to quality outcomes.
Question 6: Which statute prohibits physicians from referring Medicare patients to entities in which the physician has a financial interest?
- Anti-Kickback Statute
- Stark Law (Physician Self-Referral Law) (Correct answer)
- False Claims Act
- EMTALA
Correct answer: Stark Law (Physician Self-Referral Law)
The Stark Law prohibits self-referral for designated health services billed to Medicare or Medicaid unless a specific exception applies.
Question 7: Hospital readmission rates are most commonly tracked over what time period for quality measurement purposes?
- 7 days post-discharge
- 30 days post-discharge (Correct answer)
- 60 days post-discharge
- 90 days post-discharge
Correct answer: 30 days post-discharge
CMS and most quality programs measure 30-day all-cause readmission rates and penalize hospitals with excessive readmissions under the Hospital Readmissions Reduction Program.
ABPS Healthcare Systems & Administration 3
What is the primary goal of a Health Maintenance Organization (HMO)?