SOA Exam CSP-GH Spring 2011 Section 1 Flash Cards

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Title: SOA Exam CSP-GH Spring 2011 Section 1
Description: Flashcards for SOA exam CSP Group Health Spring 2011
Number of Cards: 12
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Author: aahahn
Created: 2012-01-23
Tags: actuarial csp gh soa
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    • Question
    • Answer
    • Side 3
    • Reasons Quality of Care is Important
    • 1. Errors Occur in the Delivery of Health Care Services - Impact employer health care costs and employee productivity
      2.Overuse of Health Care Services - Geographic differences; As much as 1/3 of certain procedures are inappropriate
      3. Underuse of Health Care Services - Failure to perform services known to be beneficial; Variations by geography, medical condition, gender, race and health plan
      4. Employer Liability - May be liable for poor quality care
      5. Employee, Provider and Community Relations - To attract and retain good workers; Physicians can impact the employees opinions on quality of the plan
    • Three Main Components of Quality Health Care
    • 1. Appropriateness - Is the care appropriate given the current technologies and protocols
      2. Excellence in Execution - Measured by the process and the outcome of care
      3. Patient Satisfaction
    • Items to consider when assessing Quality of care
    • Physicians
      1. Current unrestricted license to practice in the state
      2. Current unrestricted license to dispense prescription drugs
      3. Certification by a specialty board recognized by the American Board of Medical Specialties
      4. Current, active, unrestricted hospital staff privileges

      MCOs
      1. Credentialing criteria/processes for physicians, hospitals and ancillary providers - How often?; Are they verified?
      2. The most recent quality assurance, quality management or CQI plan and report
      3. Routine provider quality profiles - reliability of data
      4. Reimbursement formula for physicians in the MCO - Any financial incentives?
      5. Preventive care programs offered and participation rates - programs offered; Cost
      6. Plan-wide measures of Quality - HEDIS used?
    • Resources Available for Assessing Physician's Credentials
    • 1. American Board of Medical Specialties
      2. American Medical Association
      3. HealthGrades.com
      4. Federation of State Medical Boards
      5. State licensing board
    • Questions to Ask a Hospital when Evaluating Quality
    • 1. Volume of admissions for a given procedure
      2. Complication/mortality rate for a given procedure
      3. Success rate for a given procedure
      4. Average length of stay for a given procedure
      5. Results of the most recent patient satisfaction survey
      6. Participation in any managed care networks
      7. Center for Excellence designations
    • Accrediting Organizations and Accreditations to look for when Evaluating MCO Quality
    • Accrediting Orginizations
      1. Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
      2. National Committee for Quality Assurance

      Accreditations
      1. Current and unrestricted state license
      2. Current and unrestricted full accreditation from CMS
      3. Current and unrestricted full accreditation from JCAHO
    • NCQA Certification Process
    • 1. Review of the MCO quality-related systems such as
      a. Quality improvement
      b. Process for reviewing and authorizing medical care
      c. Quality of provider network
      d. Members rights and responsibilities

      2. A site survey involving both physicians and administrative reviewers is conducted

      3. Standardized HEIDIS reporting is required
    • Levels of NCQA Accreditation
    • 1. Excellent - Performance meets or exceeds requirements; HEIDIS among highest nationally or regionally
      2. Commendable - Performance meets or exceeds requirements
      3. Accredited - Performance meets most requirements
      4. Provisional - Performance meets some but not all requirements
      5. Denied - Fail
      6. Suspended - Accreditation has been withdrawn for corrective action
      7. Under review - at plan's request
      8. Discretionary Review
    • Levels of JCAHO Accreditation
    • 1. Provisional accreditation
      2. Accreditation with commendation
      3. Accreditation with or without recommendations
      4. Conditional accreditation
      5. Nonaccreditation
    • Guidelines for an Onsite Provider Visit as Part of a Quality Assurance Assessment
    • 1. Allow 4-8 hours
      2. Limit time devoted to marketing/presentations
      3. Arrange to meet key staff
      4. Spend most time observing operations and questioning staff
      5. Discuss quality-related information provided prior to the site visit
      6. Assess the philosophy of the MCO for a good fit
    • Resources Available for Assessing an MCOs Credentials
    • 1. National Committee for Quality Assurance NCQA
      2. America's Health Insurance Plans (AHIP)
      3. National Coalition on Health Care
      4. Institute for Health Care Improvement (IHI)
      5. Centers for Medicare and Medicaid Services (CMS)
      6. Agency for Health Research Quality (AHRQ)
      7. Foundation for Accountability
    • Methods for Improving Quality
    • Supply Side:
      1. Accomplished through providers banding together in purchasing or policymaking
      2. Feedback to hospital/medical staff can encourage quality improvement activities
      3. Direct contracts may enhance the responsiveness of MCOs to quality evaluation

      Demand Side

      1. Increased demand for preventive services can lead to improved quality of care
      2. Consumer - directed support can alter patient preferences for treatment types
      3. Information about provider quality can steer patients to quality providers
      4. Nurse advice lines reduce cost and improve appropriateness of health care