Question 1
Which statement best describes typical strategies to address social determinants of health within managed care?
Correct Answer:
Screenings, risk stratification, community partnerships, and services addressing housing, transportation, food, and social support.
Explanation:
Addressing social determinants of health within managed care means identifying nonmedical barriers that affect access to care and health outcomes, then connecting members to the right supports. Screenings in care settings help uncover issues like housing instability, food insecurity, transportation gaps, and weak social support. Risk stratification uses data to pinpoint individuals with high social needs who are at greater risk for expensive care, so resources can be targeted where they’ll have the most impact. Building strong community partnerships with housing programs, food assistance, transportation services, and social support organizations enables seamless referrals and action. Services that address housing, transportation, food, and social support remove practical barriers to care, support treatment adherence, and can reduce hospitalizations and costs. In managed care, these components are implemented through care management processes, with referrals, coordinators, and follow-up to monitor outcomes. Options that focus only on eliminating social services, on pharmaceuticals alone, or on emergency department interventions miss these upstream, proactive strategies and tend to be less effective and more costly.
Question 2
What is the purpose of stop-loss in risk-sharing arrangements?
Correct Answer:
It reimburses claims above a predetermined threshold, limiting risk exposure.
Explanation:
Stop-loss acts as a safety net that limits financial risk from unusually high claims by reimbursing them only after a preset threshold is reached. In risk-sharing arrangements, this means the plan covers costs up to the threshold, and the stop-loss carrier pays the excess, preventing a few extreme claims from destabilizing budgets. This protection brings budgeting stability and makes participating in risk-sharing more feasible, especially for self-funded or pooled arrangements. It’s not about setting a fixed premium, standardizing provider payments, or subsidizing patients’ premiums.
Question 3
In coverage determinations, which type of evidence is central to decision-making?
Correct Answer:
Clinical and Economic Evidence
Explanation:
Clinical and economic evidence drive coverage determinations. Decisions hinge on whether a treatment provides meaningful clinical benefit—improved outcomes, safety, and how it stacks up against alternatives—along with evidence on its value from an economic standpoint, such as cost-effectiveness and budget impact. This combination helps determine not only if a therapy works, but whether its benefits justify its costs within a payer’s resources. Anecdotes from patients lack generalizability and rigorous methods; marketing materials are biased and not objective evidence; celebrity endorsements do not reflect medical value or cost considerations. Together, rigorous clinical data and solid economic analysis form the basis for deciding if a service should be covered.
Question 4
Which of the following describes the complete set of health care outcomes used for evaluation?
Correct Answer:
Cost, quality, access, and equity
Explanation:
Evaluating health care outcomes comprehensively means looking at four interconnected areas: cost, quality, access, and equity. Cost reflects the economic impact and efficiency of care. Quality covers how well care achieves desired health outcomes, including safety and effectiveness. Access measures how readily people can obtain care, including availability and timeliness. Equity addresses fairness and the extent to which outcomes are consistent across different populations. If you focus on only one aspect, you don’t get the full picture. Equity of care concentrates on fairness alone and misses cost, access, and quality. Quality and patient satisfaction emphasize the experience and effectiveness but don’t by themselves account for cost or disparities. Utilization and risk factors examine resource use and determinants, not the complete set of outcomes used to evaluate overall performance. Therefore, combining cost, quality, access, and equity provides the full set of health care outcomes used for evaluation.
Question 5
Which statement about applying social determinants of health (SDoH) in care management is most accurate?
Correct Answer:
Screen for SDoH, partner with social services, provide navigation and support for housing, transportation, and food security, and track outcomes to measure SAMPLEimpact.
Explanation:
Addressing social determinants of health in care management means acting proactively to identify and remove barriers that affect health outcomes. Screening for SDoH uncovers issues like housing instability, transportation gaps, and food insecurity that can derail treatment and adherence. Partnering with social services creates a bridge to resources, while providing navigation and support helps patients actually access and use those resources for housing, transportation, and food needs. Tracking outcomes is essential to show whether these efforts improve access, adherence, health status, and utilization, and to guide refinements over time. This approach goes beyond clinical care alone by integrating external supports and measuring real-world impact, which is why it is the most accurate representation of applying SDoH in care management.
Question 1
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Prepare with the Kogut's Managed Care Practice Test practice quiz. This question bank includes 10 questions covering describes, health, care, social, and determinants. Use it to review important concepts, identify knowledge gaps, and build confidence for the related exam, course, or assessment.

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Kogut's Managed Care Practice Test

This practice set contains 10 questions from the matching question bank and focuses on describes, health, care, social, and determinants. Work through each question carefully, review the provided solutions, and revisit topics that need more study before your next attempt.

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