Question

If an enrollee seeks health services care from a non-managed care panel specialist without a referral from the primary care physician, this is known as a(n)_________.

1) fee-for-service
2) adverse selection
3) risk contract
4) self-referral

Answer 1

When an enrollee chooses to visit a specialist without a primary care physician's referral, it is known as a self-referral. This practice contrasts with the structured referral systems in place within Health Maintenance Organizations and can lead to higher healthcare costs.

Step-by-step explanation:

If an enrollee seeks health services care from a non-managed care panel specialist without a referral from the primary care physician, this is known as a self-referral. In managed care systems like Health Maintenance Organizations (HMOs), enrollees typically need a referral from their primary care physician to see a specialist. This process helps maintain cost controls and ensures that the care provided is necessary. Without this referral, when patients directly visit specialists, it is a self-referral, which can lead to higher costs and utilization of services.

Understanding adverse selection is also crucial in health financing. It occurs when there is asymmetric information between the insurance company and the insured individuals, leading high-risk individuals to seek insurance more often than low-risk individuals, potentially disturbing the insurance market.

The Patient Protection and Affordable Care Act (ACA or Obamacare), aimed to address such issues by mandating insurance coverage and preventing the denial of coverage based on preexisting conditions, thus attempting to create a more balanced pool of insured individuals.