Administration Test 1 Set 1

Front 1

When did Insurance come about

Back 1

30s/40s/WW2

Front 2

USA as a country is an exception to insurance how?

Back 2

only industrialized nation to not have universal health insurance

Front 3

How does health insurance break down for 10 ppl

Back 3

1)8/10 better off w/o HI
2)1/10 breaks even w/ premium costs
3)1/10 is catastrophic

Front 4

Payer

Back 4

employers, company financing the HI program

Front 5

Subscribers

Back 5

employees getting the HI

Front 6

Dependents

Back 6

spouse, kids, CAN be parents thou

Front 7

Enrollees
a)def
b)2 other terms

Back 7

a)how many ppl do we (the company) cover
b)members, covered lives

Front 8

Gov't refers to subscribers as... (3)
Mental Health refers to subscribers as... (2)

Back 8

a)beneficiaries, enrollees, elgibles
b)clients, consumers

Front 9

Providers def (2)

Back 9

1)in pharmacy it is the pharmacy
2)in medicine its the MD

Front 10

#1 payer is ___ via...

Back 10

GOV'T via medicare, medicaid, armed services

Front 11

Large corporations may qualify to be "SELF-INSURED"?

Back 11

not subject to certain state regulations governing HC benefits

Front 12

MCO general def

Back 12

entity involved in providing a HI program

Front 13

MCO refers to... (4)

Back 13

1)HMOs
2)PPO
3)POS plans
4)many other

Front 14

CoC? (3)

Back 14

1)certificate of coverage
2)legal contract b/w health plan and the purchasing employer group
3)AETNA and OU have one

Front 15

Risk?

Back 15

financial cost the insurer may incur in offering HC coverage to a certain population

Front 16

Premium? and is based upon...

Back 16

monthly fee the employer group must pay to purchase HI benefits; based upon projected financial risk

Front 17

"Underwriting"?

Back 17

process of projecting financial risk

Front 18

Risk pool
a)def
b)value of one

Back 18

a)Reason why group plans are less costly b/c financial risk is spread over many members
b)costs generated by catastrophic HC can spread over entire risk pool and be less financially devastating

Front 19

Most expensive type of insurance?

Back 19

individual insurance

Front 20

____ is traditional insurance (and is the main type in OK)

Back 20

indemnity insurance or FFS

Front 21

Why was MCO introduced originally?

Back 21

no cost or utilization controls imposed by the indemnity system

Front 22

BCBS
a)is...
b)reason for existance originally

Back 22

a)FFS/indemnity insurance
b)to get payment for MD's services

Front 23

Shift towards MCO began...and why? and how it worked?

Back 23

in 1970s, employers inability to keep pace w/ rising HC costs

narrowed scope of coverage and capped amt they would pay for services

Front 24

First 2 prepaid health plans

Back 24

1)farmer's cooperative in rural oklahoma
2)baylor hospital

Front 25

Kaiser Permanente system
a)how worked
b)who b/w

Back 25

a)Kaiser gave capitated amt per month and MD took risk to guarantee medical care for that amount
b)Henry Kaiser, industralist and Sidney Garfield, MD

Front 26

Factors in 60s/70s that contributed to unacceptable HC inflation (3 of many)

Back 26

2)labor costs for HC personnel were increasing
3)MDs were specializing w/ increasing frequency
4)unnecessary services were paid for under FFS indemnity

Front 27

HMO Act of 1973 was gov't first attempt to...

Back 27

move toward disciplined control of HC spending and use

Front 28

HMO Act of 1973 included... (4)

Back 28

1)financial incentives to encourage development of HMOs
2)ability to become "federally qualified HMOs" giving them legal/marketing advantages
3)inclusion of preventative and curative HC benefits
4)require that employers offer federally qualified HMOs to employees under certain circumstances

Front 29

Advantage of federally qualified HMO? (3)

Back 29

1)employers of 25+ were req'd to offer 2+ of them
2)elgible to obtain certain grants and loans
3)implied accreditation (giving marketing advantage)

Front 30

TERRA (tax equity and fiscal responsibility Act) led to...

Back 30

medicare risk-contracting program; gov't attempt to intro HMOs to control HC costs for medicare beneficiaries

Front 31

2 components that distinguish a HC insurance option

Back 31

1)financing of HC services
2)delivery of HC services

Front 32

Financing? (2)

Back 32

1)flow of $ among employers, members and providers
2)type/degree of financial risk sharing

Front 33

Delivery?

Back 33

how members access the system and recieve HC

Front 34

.....the more effectively the system will contain costs (2)

Back 34

1)more stakeholders are @ financial risk for services
2)greater control over access to services

Front 35

Relationship b/w benefit controls and physician/member satifaction (2)

Back 35

1)few benefit controls = high MD/member satifaction
2)highly controlled benefits = low MD and member satisfaction

Front 36

Relationship b/w benefit controls and costs (2)

Back 36

1)few benefit controls = higher costs
2)highly controlled benefits = lower costs

Front 37

Continuum of control and cost containment (5)

Back 37

1)managed indemnity = least control and higher costs
2)PPO
3)POS HMO
4)IPA/Network HMO
5)Staff/Group HMO = highest control and lowest costs

Front 38

Staff HMO (3 and best ex/OK ex)

Back 38

1)employ MD's
2)treat members in facilities owned by HMO
3)pharmacy services provided by in-house pharmacies
4)Group Health Cooperative of Puget Sound, VA in OK

Front 39

Group HMO (2 and 2 ex)

Back 39

1)contract w/ MD group to provide care
2)limited to providing care for only the HMO enrollees

1)Kaiser Permanente Health Plan
2)GlobalHealth Plan

Front 40

Network HMO (2 and 1ex)

Back 40

1)contract w/ more than one community based MD practice to offer geographic coverage
2)pharmacy services offered thru in-house pharmacies

1)CommunityCare

Front 41

IPA model HMO (4 and 1ex)

Back 41

1)no medical facilities of own
2)contract w/ independent community-based MD's
3)will also conttact w/ community hospitals and other HC providers
4)out of house pharmacy services

1)BlueLincs (part of BCBS)

Front 42

PPO's (2)

Back 42

1)contracted MD, hospitals organized by insurance carrier to provide HC
2)cheaper than indemnity, more than HMOs

Front 43

POS (4)

Back 43

1)hybrid of PPO/HMO
2)use HMO provider network
3)get care for lowest OOP cost
4)for more than lowest OOP you can get access to more providers

Front 44

EPO (2)

Back 44

1)like PPO but require members to only access contracted providers
2)established directly by employer w/ goal of cost containment

Front 45

Physician-hospital organizations (PHOs) (2)

Back 45

1)owned by hospital and affiliated MD's
2)comprehensive delivery system that contracts w/ HMOs

Front 46

Most plans in OK are...

Back 46

"any willing provider"

Front 47

Physician reimbursement mechanisms for...
a)physicians employed by staff model HMO
b)group model HMO
c)IPA model HMO

Back 47

a)salaried
b)salaried or reimbursed thru capitation
c)capitation or discounted FFS

Front 48

Capitation reimbursement (2)

Back 48

1)fixed monthly fee for providing services based upon the # of enrolled members that are assigned to him
2)lump sum per month regardless of pts health needs

Front 49

Discounted FFS reimbursement (2)

Back 49

1)recieve payment whenever providing covered services
2)but it is discounted from U&C reimbursement rates

Front 50

Main reimbursement process in pharmacy

Back 50

discounted FFS

Front 51

Gatekeeper physician (3)

Back 51

1)HMO member must select a primary care physician (PCP)
2)PCP coordinates all care for the member
3)PCP must approve all specialty referrals, nonemergency hospitalizations

Front 52

Risk Sharing of Pharmacy Cost?

Back 52

reimbursement for capitated physicians may be impacted by the medication costs of their prescribing

Front 53

Growth of managed care has been resisted by managed care and MD's b/c...(2)

Back 53

1)manages provider behavior
2)atithetical to autonomy MD's and pharmacists have enjoyed in the past

Front 54

Difference b/w amt of premium received by HMO and amt of premium spent on HC delivery is...and exp of it (0.93)

Back 54

MEDICAL LOSS RATIO

0.93= $0.93 of every dollar recieved goes toward direct medical and $0.07 towards administration

Front 55

Sharing risk w/ all stakeholders is applied to managed care members via...(2)

Back 55

1)choice to select what type of HC coverage they want from the alternatives offered by their employer
2)pay a copay/coinsurance whenever they access their benefits

Front 56

FDA has authority over... (4)

Back 56

1)marketing
2)toxicology
3)clinical trials
4)marketing/distribution

Front 57

FDA has the power to...

Back 57

declare a drug misbranded or adulterated

Front 58

Adulteration of a drug?

Back 58

fail to meet standards or diverge from requirements of good manufacturing practices

Front 59

____ is responsible for HUMAN DRUG PRODUCTS

Back 59

Center for Drug Eval and Research (CDER)

Front 60

____ is responsible for human biological products

Back 60

Center for Biologics Eval and Research

Front 61

FDA may issue GUIDANCES to...

Back 61

explain its current thinking on interpretation of the FD&C Act

Front 62

Purpose of GUIDANCE is.... (2)

Back 62

1)provide assistance by clarifying requirements and explaining how to comply
2)provide review and enforcement approaches to implement the FDA's mandates

Front 63

Net result of "Promoting Medical Products in a Changing HC Environment: Medical Product Promo by HC Organizations..."

Back 63

communications of managed care organizations would be subject to FDA regulation

Front 64

Those in favor of DTC claim (3)

Back 64

1)it meets consumer demand for greater access to HC info
2)notifies consumers to seek eval for conditions they might ignore
3)provides for a more informed public

Front 65

Those opposed to DTC claim (3)

Back 65

1)interferes w/ pt-provider relationship
2)increases drug costs
3)confuses pts

Front 66

DTC is regulated by...

Back 66

FDA

Front 67

CONSUMER Bill of Rights
a)established by...
b)was a part of...
c)3 goals

Back 67

a)Clinton
b)Advisory Committee on Consumer Protection and Quality in HC
c1)strengthen consumer confidence
c2)reaffirm importance of strong relationship b/w pts and providers
c3)reaffirm critical role consumer play in safeguarding their own health

Front 68

PATIENT Bill of Rights
a)established by...
b)set standards for what aspects of pt care (4 among many)

Back 68

1)Info disclosure on health plans, health professionals/facilities
2)Confidentiality of Health Info
3)Respect and Nondiscrimination
4)Choice of Providers/Plans

Front 69

2 types of medical info in pt privacy issues

Back 69

1)pt-identifiable data
2)nonidentifiable data

Front 70

1 Other argument against DTC and should be...

Back 70

leads to inappropriate demand for advertised therapies

DTC should be focused on disease NOT the product

Front 71

HIPAA recommendations were based on 5 key principles

Back 71

1)boundaries
2)security
3)consumer control
4)accountability
5)public responsibility

Front 72

HIPAA
a)allows for.. (3)
b)came about b/c of...

Back 72

a1)utilization review by pharmacist or "business associate"
a2)prevent individual ID by researchers of databases
a3)penalties for breaches in security
b)HACKERS

Front 73

If a database breach occurs....(this is under public responsibilites)

Back 73

must contact ALL ppl in breach

Front 74

Under BOUNDARIES of HIPAA 4 situations in which health info is collected, disclosed or used

Back 74

1)provision of and payment for HC
2)service organizations
3)limited disclosures for national priorities
4)disclosure w/ authoization

Front 75

SECURITY of HIPAA encompasses.... (3 of many)

Back 75

1)disclosure of pt identifiable data
2)implementation of security to protect info
3)requirements that disclosures be limited to the minimum necessary to accomplish the purpose of the disclosure

Front 76

CONSUMER CONTROL of HIPAA is that Americans should... (3)

Back 76

1)know what rules protect their health records
2)how those records would be used/shared
3)how they could obtain their records

Front 77

ACCONTABILITY of HIPAA is...

Back 77

1)safeguard info w/ real and severe penalties for violations

Front 78

PUBLIC RESPONSIBILITY of HIPAA would allow for limited disclosures of health info w/o pt consent for specifical ID'd national priority activities (what are 4 national priority activities)

Back 78

1)oversight of HC system
2)public health, and in emergencies affecting life or safety
3)health research under certain circumstances
4)pursuant to other laws

Front 79

Medicare/caid ANTIKICKBACK statutes penalize anyone who...

Back 79

offers/pays for the inducement to purchase an item or service reimbursable under the Medicare/caid programs

Front 80

Provider license revocation when a provider engages in ____ which includes...

Back 80

"unprofessional conduct"

receipt of rebates/discounts for prescribing a particular drug

Front 81

Drug switch?

Back 81

dispensing one medication for the one originally prescribe w/ or w/o the prescribers permission BASED UPON PROTOCOLS (hospitals)

Front 82

Therapeutic Interchange

Back 82

call Dr to get permission to change drug

Front 83

Therapeutic Substitution

Back 83

Change w/o prescriber's approval (like drug switch)

Front 84

Incr in therapeutic interchange and substitution for 3 reasons

Back 84

1)incr in # of drugs in same therapeutic classes
2)need to contain Rx drug costs
3)also good for making a more convenient dosing schedule

Front 85

Purpose of MedWatch?

Back 85

FDA requested reports of adverse events associated w/ therapeutic switches

Front 86

Narrow Therapeutic Ratio is defined as...(3)

Back 86

1)less than 2fold difference in LD50 and ED50
2)less than 2fold difference in minimum toxic []s and minimum effective []s in the blood
3)safe and effective use of drug products requires careful titration and pt monitoring

Front 87

Generic drugs must meet FDA standards for... (4)

Back 87

1)chemistry
2)manufacturing and controls
3)labeling
4)bioequivalence

Front 88

In establishing bioequivalence you must look at... (4)

Back 88

1)AUC
2)peak [] (Cmax)
3)time to Cmax
4)elimination rate and half-life

Front 89

Drug Product Selection is the...and why is the term GENERIC SUBSTITUTION a bad term?

Back 89

selection of a generically equivalent medication (THIS IS WHAT PHARMACISTS CAN LEGALLY DO)

medical community thinks you mean a generic in the therapeutic category (NOT brand for generic)

Front 90

Employee Retirement Income Security Act (ERISA) was adopted to...and requires...

Back 90

ensure that employer-sponsored benefit plans are uniformly developed and admin

employer and "plan fiduciaries" to conduct and admin employee benefit plans in a certain manner

Front 91

ERISA defines a "plan fiduciary" as.... (3)

Back 91

any person or entity that
a)exercises discretionary control
b)provides investment advice regarding the finances
c)has any discretionary authority

Front 92

Department of Labor has ID'd fxns that may be considered nondiscretionary (3 of many)

Back 92

1)calculation of service and compensation credits
2)preparation of employee communications
3)claims processing

Front 93

A plan fiduciary has the obligation to...(3 of many)

Back 93

1)act solely in the interest of the plan's participants
2)act for the exclusive purposes of providing benefits to participants
3)diversify the investments of the plan to minimize risk of large losses

Front 94

ERISA prohibited transaction provisions prohibit two types of conduct by the plan fiduciary

Back 94

1)cant engage in specified transactions w/ a "party in interest"
2)cant profit personally at the expense of the plan

Front 95

"Party of interest"? (3)

Back 95

1)another fiduciary plan
2)plan service provider
3)corporation of which 50% is owned by the plan

Front 96

ERISA has 3 basic components to the preemption provisions

Back 96

1)preemption clause
2)savings clause
3)deemer clause

Front 97

Licensing of entities that manage pharmacy benefits; the most common licensing frameworks are... (4)

Back 97

1)third party administrator (this is now PBM)
2)PPO
3)utilization review organization
4)third-party Rx program

Front 98

PBM is a system of providing...

Back 98

providing reimbursement for pharmacy services and pharmaceuticals under contract b/w a provider and another party

Front 99

PPO has 2 goals

Back 99

1)protecting providers
2)protecting consumers

Front 100

General def of PPO

Back 100

entities that contract w/ providers to provide services to covered persons @ a contracted reimbursement rate