CPE Healthcare Policy & Advocacy 3 — Questions and Answers
Question 1: Which payment model ties a percentage of physician compensation directly to performance on clinical quality and patient experience metrics?
- Capitation
- Fee-for-service
- Pay-for-performance (P4P) (Correct answer)
- Retrospective cost-sharing
Correct answer: Pay-for-performance (P4P)
Pay-for-performance programs explicitly link a portion of provider payment to measured outcomes, process metrics, or patient satisfaction scores.
Question 2: A hospital system lobbying for favorable Medicaid DSH (Disproportionate Share Hospital) funding should understand that DSH payments are primarily designed to:
- Reward hospitals achieving top-quartile quality scores
- Compensate hospitals that serve a high proportion of low-income and uninsured patients (Correct answer)
- Fund graduate medical education at teaching hospitals
- Offset uncompensated care from EMTALA obligations only
Correct answer: Compensate hospitals that serve a high proportion of low-income and uninsured patients
DSH payments help hospitals that treat a large share of Medicaid and uninsured patients offset the financial losses associated with uncompensated care.
Question 3: Under the ACA's essential health benefits (EHB) framework, which of the following is NOT one of the ten required benefit categories?
- Maternity and newborn care
- Mental health and substance use disorder services
- Dental and vision for adults (Correct answer)
- Prescription drugs
Correct answer: Dental and vision for adults
Adult dental and vision are not included in the ACA's ten essential health benefit categories, though pediatric dental and vision are required.
Question 4: A physician executive wants to influence a proposed CMS rule during the rulemaking process. The most effective formal mechanism is to:
- File a lawsuit challenging CMS authority under the APA
- Submit written comments during the public comment period of notice-and-comment rulemaking (Correct answer)
- Lobby Congress to pass superseding legislation immediately
- Request an Inspector General investigation of the rule's basis
Correct answer: Submit written comments during the public comment period of notice-and-comment rulemaking
The Administrative Procedure Act's notice-and-comment process is the primary formal channel for stakeholders to influence proposed federal regulations before finalization.
Question 5: In Accountable Care Organizations (ACOs), 'shared savings' are distributed to the ACO when:
- The ACO's total spending exceeds the benchmark by less than 5%
- Actual spending falls below the established benchmark and quality thresholds are met (Correct answer)
- Individual physicians achieve top decile HEDIS scores
- The ACO enrolls more than 10,000 attributed beneficiaries
Correct answer: Actual spending falls below the established benchmark and quality thresholds are met
ACOs earn shared savings by keeping total expenditures below a risk-adjusted spending benchmark while meeting minimum quality performance standards.
Question 6: The concept of 'all-payer claims databases' (APCDs) is most valuable for healthcare policy because they:
- Allow payers to collectively negotiate lower provider rates
- Enable analysis of healthcare utilization and cost across all payers in a market (Correct answer)
- Replace state Medicaid management information systems
- Create a federal price-setting mechanism for hospital services
Correct answer: Enable analysis of healthcare utilization and cost across all payers in a market
APCDs aggregate claims data from multiple payers to give policy makers and researchers a comprehensive view of costs, utilization, and outcomes across a population.
Question 7: Which legislative strategy involves attaching a healthcare provision to a must-pass spending bill to avoid a standalone floor vote?
- Conference committee substitution
- Rider or amendment attachment (Correct answer)
- Unanimous consent agreement
- Cloture filing
Correct answer: Rider or amendment attachment
A rider is a legislative provision added to an unrelated bill—often an appropriations measure—to ensure it passes without facing an independent vote.
CPE Healthcare Policy & Advocacy 3
Which payment model ties a percentage of physician compensation directly to performance on clinical quality and patient experience metrics?