1) What is the goal of managed health care? What does it strive to do?
2) What is the role of a primary care physician (PCP) in a traditional HMO?
3) Explain how capitation works in regard to physician reimbursement.
4) Have pay-for-performance (P4P) programs been effective? Why or why not?
5) Differentiate between pre-auth and pre-cert.
6) List two advantages and two disadvantages for a health plan using a PBM to manage its pharmacy services rather than developing or building these services internally.
7) List two examples of tools that a health plan can use to promote disease prevention among its members.
8) Administrative claims data can serve many different uses for reporting and analysis in managed care. List two potential uses.
9) Members contact their health plans for a variety of reasons. List two of these reasons.
10) Medicaid managed care serves a population with complex needs. List and explain two operational challenges faced by Medicaid managed care.