AHM-540 Online Practice Questions and Answers

Private employers are key purchasers of health plan services. The following statement(s) can correctly be made about employer expectations about the quality and cost- effectiveness of healthcare services:

1.

For both health maintenance organizations (HMOs) and non-HMO plans, employers typically have access to accreditation results and performance measurement reports to help them evaluate the quality of healthcare and service

2.

Because of employers' concern about the quality and costs of healthcare services available through health plans, direct contracting has become a dominant model among employers who sponsor health benefit programs for their employees

A. Both 1 and 2

B. 1 only

C. 2 only

D. Neither 1 nor 2

Determine whether the following statement is true or false:

The delegation of medical management functions to providers can occur without the transfer of financial risk.

A. True

B. False

Comorbidity can have a significant impact on the effective implementation of disease management programs. Comorbidity can correctly be defined as the

A. degree to which the progression of a disease or condition is understood

B. prevalence or rate of a sickness or injury within a given population

C. degree of severity of a particular disease or condition

D. presence of a chronic condition or added complication other than the condition that requires medical treatment

In recent years, the demand for prescription drugs has increased dramatically. Factors that have contributed to this increase include

A. increased education regarding the purpose and benefits of drug formularies

B. reductions in the cost of prescription drugs

C. increased use of direct-to-consumer (DTC) advertising

D. all of the above

Helena Ray, a member of the Harbrace Health Plan, suffers from migraine headaches. To treat Ms. Ray's condition, her physician has prescribed Upzil, a medication that has Food and Drug Administration (FDA) approval only for the treatment of depression. Upzil has not been tested for safety or effectiveness in the treatment of migraine headache. Although Harbrace's medical policy for migraine headache does not include coverage of Upzil, Harbrace has agreed to provide extra-contractual coverage of Upzil for Ms. Ray.

The following statement(s) can correctly be made about Harbrace's use of extra- contractual coverage:

1.Harbrace's medical policy most likely establishes the procedure that Harbrace used to evaluate the value of Upzil for treating Ms. Ray

2.One way for Harbrace to reduce the risk associated with extra-contractual coverage is by including an alternative care provision in its contracts with purchasers

A. Both 1 and 2

B. 1 only

C. 2 only

D. Neither 1 nor 2

State governments serve as both regulators and purchasers of health plan services. The influence of state governments as purchasers is focused on

A. Medicare and TRICARE programs

B. Medicaid and workers' compensation programs

C. Medicare and Medicaid programs

D. TRICARE and workers' compensation programs

Demetrius Farrell, age 82, is suffering from a terminal illness and has consulted his health plan about the care options available to him. In order to avoid unwanted, futile interventions, Mr. Farrell signed an advance directive that indicates the types of end-of-life medical treatment he wants to receive. His family is to use this document as a guide should Mr. Farrell become incapacitated.

For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.

Decisions regarding Mr. Farrell's end-of-life care are legally the right and responsibility of

A. Mr. Farrell and his family

B. Mr. Farrell's physician

C. Mr. Farrell's health plan

D. All of the above

To improve members' abilities to make appropriate care decisions about specific medical problems, some health plans use a form of decision support known as telephone triage programs. The following statements are about telephone triage programs. Select the answer choice containing the correct statement.

A. The primary role of telephone triage clinical staff is to diagnose the caller's condition and give medical advice.

B. Quality management (QM) for telephone triage programs typically focuses on the clinical information provided rather than on the quality of service.

C. Currently, none of the major accrediting agencies offers an accreditation program specifically for telephone triage programs.

D. A telephone triage program may also include a self-care component.

The Shoreside Health Plan recently added coverage for behavioral healthcare services to its benefit package. In order to support the quality of its behavioral healthcare services, Shoreside plans to seek accreditation for its behavioral healthcare program. Accreditation specifically designed for behavioral healthcare programs is available through 1.The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

2.The National Committee for Quality Assurance (NCQA)

3.The American Accreditation HealthCare Commission/URAC (URAC)

A. All of the above

B. 1 and 2 only

C. 2 and 3 only

D. 1 only

This agency's accreditation decisions are based on the results of an on-site survey of clinical and administrative systems and processes, as well as the health plan's performance on selected effectiveness of care and member satisfaction measures.

A. American Accreditation HealthCare Commission/URAC (URAC)

B. Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

C. Community Health Accreditation Program (CHAP)

D. National Committee for Quality Assurance (NCQA)

In order to provide a true measure of quality, the data collected by a quality indicator should accurately represent the service dimension being measured. This information indicates that the indicator should exhibit the characteristic known as

A. clarity

B. reliability

C. validity

D. feasibility

The following statements are about chronic and disabling conditions among children eligible for Medicaid. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

A. Children with chronic conditions use more physician and nonphysician professional services than do children in the general population.

B. The majority of chronic conditions affecting children in Medicaid programs are the same as those affecting children in the general population.

C. Medicaid-eligible children are at risk for seriousmental and physical conditions.

D. Children in Medicaid programs have a higher incidence of chronic disabling conditions than do children in the general population.

The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Determine which term or phrase in each pair correctly completes the paragraph. Then select the answer choice containing the two terms or phrases that you have selected.

The process for collecting and analyzing data differs for quality assessment (QA) and quality improvement (QI). For QA, data collection focuses on (objective / both objective and subjective) data, and data analysis identifies the (degree / cause) of variance.

A. objective / degree

B. objective / cause

C. both objective and subjective / degree

D. both objective and subjective / cause

The case management team at the Hightower Health Plan reviewed the medical records of the following two plan members to determine the type of care each one needs and the most appropriate setting for that care:

Ira Morton was hospitalized for a severe stroke. Although his medical condition is stable, the stroke left him partially paralyzed and he will require extensive rehabilitation and 24- hour medical care.

Theresa Finley is recovering from a total hip replacement and is in need of short-term physical therapy and twice-weekly visits from a licensed nurse to check her blood pressure and the healing of her incision.

From the answer choices below, select the response that correctly identifies the level of care that would be most appropriate for Mr. Morton and Ms. Finley.

A. Mr. Morton-acute care Ms. Finley-subacute care

B. Mr. Morton-palliative care Ms. Finley-acute care

C. Mr. Morton-subacute care Ms. Finley-skilled care

D. Mr. Morton-skilled care Ms. Finley-palliative care

Among this agency's accreditation programs are accreditation for preferred provider organizations (PPOs), health plan call centers, and case management organizations. This agency classifies its standards as either "shall" standards or "should" standards.

A. American Accreditation HealthCare Commission/URAC (URAC)

B. Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

C. Community Health Accreditation Program (CHAP)

D. National Committee for Quality Assurance (NCQA)