CPE Healthcare System and Policy 3 — Questions and Answers
Question 1: Which payment model rewards providers for keeping a defined patient population healthy and managing total cost of care within a budget?
- Fee-for-service
- Capitation (Correct answer)
- Per diem payment
- Episode-based bundled payment
Correct answer: Capitation
Capitation pays providers a fixed amount per enrolled member per month to cover all defined services, shifting financial risk to the provider.
Question 2: The MACRA legislation replaced which flawed Medicare physician payment formula?
- Resource-Based Relative Value Scale (RBRVS)
- Sustainable Growth Rate (SGR) (Correct answer)
- Diagnosis-Related Groups (DRG)
- Prospective Payment System (PPS)
Correct answer: Sustainable Growth Rate (SGR)
MACRA (2015) permanently repealed the SGR formula, which had threatened annual cuts to physician Medicare payments for years.
Question 3: A physician executive is designing a risk stratification program. Which data source is MOST useful for identifying high-risk patients likely to incur high costs?
- Patient satisfaction survey scores
- Prior year claims and utilization data (Correct answer)
- Physician specialty distribution
- Hospital bed occupancy rates
Correct answer: Prior year claims and utilization data
Prior claims and utilization data reliably identify patterns of high use, chronic conditions, and frequent hospitalizations that predict future costs.
Question 4: Under EMTALA, hospital emergency departments are required to:
- Provide free care to all uninsured patients
- Perform a medical screening exam and stabilize emergent conditions regardless of ability to pay (Correct answer)
- Transfer unstable patients to public hospitals
- Obtain prior authorization before treating non-members
Correct answer: Perform a medical screening exam and stabilize emergent conditions regardless of ability to pay
EMTALA mandates that EDs perform a medical screening examination and provide stabilizing treatment to anyone presenting with an emergency medical condition.
Question 5: The 'triple aim' framework, developed by IHI, focuses on simultaneously improving which three dimensions?
- Quality, safety, and efficiency
- Population health, patient experience, and per capita cost (Correct answer)
- Access, equity, and satisfaction
- Prevention, treatment, and rehabilitation
Correct answer: Population health, patient experience, and per capita cost
The IHI Triple Aim targets better population health, improved patient experience of care, and reduced per capita healthcare costs.
Question 6: A hospital implements a Condition of Participation (CoP) compliance program. These conditions are set by which entity?
- Joint Commission
- State health departments
- Centers for Medicare & Medicaid Services (CMS) (Correct answer)
- American Hospital Association
Correct answer: Centers for Medicare & Medicaid Services (CMS)
CMS establishes Conditions of Participation that healthcare organizations must meet to participate in Medicare and Medicaid programs.
Question 7: Accountable Care Organizations (ACOs) in the Medicare Shared Savings Program are designed to achieve savings by:
- Limiting the number of specialists patients can see
- Coordinating care to reduce unnecessary utilization while meeting quality benchmarks (Correct answer)
- Requiring all services to be delivered within a single hospital system
- Mandating generic drug substitution for all prescriptions
Correct answer: Coordinating care to reduce unnecessary utilization while meeting quality benchmarks
ACOs share in savings generated when they coordinate care effectively to keep costs below a benchmark while meeting quality performance thresholds.
CPE Healthcare System and Policy 3
Which payment model rewards providers for keeping a defined patient population healthy and managing total cost of care within a budget?