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  3. A major health insurance company in Lagolia pays for special procedures prescribed by physicians only if the procedure is first

A major health insurance company in Lagolia pays for special procedures prescribed by physicians only if the procedure is first

admin2019-11-17  15
问题 A major health insurance company in Lagolia pays for special procedures prescribed by physicians only if the procedure is first approved as "medically necessary" by a company-appointed review panel. The rule is intended to save the company the money it might otherwise spend on medically unnecessary procedures. The company has recently announced that in order to reduce its costs, it will abandon this rule.
Which of the following, if true, provides the strongest justification for the company’s decision?
选项 A、Patients often register dissatisfaction with physicians who prescribe nothing for their ailments.
B、Physicians often prescribe special procedures that are helpful but not altogether necessary for the health of the patient.
C、The review process is expensive and practically always results in approval of the prescribed procedure.
D、The company’s review process does not interfere with the prerogative of physicians, in cases where more than one effective procedure is available, to select the one they personally prefer.
E、The number of members of the company-appointed review panel who review a given procedure depends on the cost of the procedure.
答案C
解析 Evaluation of a Plan
Situation In order to cut costs, a major health insurance company is abandoning a rule stating that it will pay for special procedures only if the procedure is approved as medically necessary by a review panel.
Reasoning What piece of information would most help to justify the company’s decision? For the company to save money, it would need to be in some way cutting its costs by abandoning the rule. Under what circumstances might the rule cost, rather than save, the company money? The panel itself might be expensive to convene, for example. Further, the cost savings achieved by the panel might be minimal if the panel did not deny significant numbers of procedures.
A This suggests that patients might be pressuring their physicians to prescribe certain unnecessary procedures for their ailments, which in turn suggests that the panel is reviewing these procedures and denying them. But if so, then the panel is probably saving the insurance company money, so abandoning the panel’s review would not reduce the company’s costs.
B This suggests that certain procedures that are being prescribed by physicians are not medically necessary, which in turn suggests that the panel reviewing these procedures may be denying them. If this is the case, then the panel is probably saving the insurance company a significant amount of money, so abandoning the panel’s review may well increase rather than decrease the company’s costs.
C Correct. This statement properly identifies information that would help to justify the company’s decis on.
D Even if the panel does not interfere with physicians’ choices when more than one medically effective procedure is available, the panel may still be denying pay for many procedures that are not medically necessary. In such cases the panel may be saving the insurance company money, and abandoning the review process would not reduce the company’s costs.
E This suggests that the more expensive the procedure under review, the more expensive the panel itself’s. Even so, if the panel denies payment for very expensive procedures, it may nonetheless save the company significantly more than the company has to pay to convene the panel, so abandoning the review process would not reduce the company’s costs.
The correct answer is C.
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