Administration Test 1 Set 4

Front 1

The 3 primary PBM customer groups

Back 1

1)MCOs
2)Gov't sponsored programs
3)self-insured employer groups

Front 2

T/F; Carve out is unique to pharmacy

Back 2

false

Front 3

DPS; Express Scripts came from...

Back 3

MCOs

Front 4

Medco came from....

Back 4

Govt programs

Front 5

PCS; Caremark came from....

Back 5

self-insured programs

Front 6

PBMs developed thru 1 of 2 distinct channels

Back 6

1)separate independent companies
2)from within HMOs

Front 7

PCS/Caremark developed to...

Back 7

1)offer TP Rx benefits to employer groups w/ a vast network of pharmacies

Front 8

Medco's development was focused on....

Back 8

mail service to dispense Rx's

Front 9

DPS/Express Scripts developed how and to do what?

Back 9

from within United HC and had a clinical focus

Front 10

Role of Formularies in PBM development (3)

Back 10

1)prevented use of expensive/unnecessary brand name drugs
2)promote use of most cost-efficient meds
3)REBATES (cover PBM costs, PBM profits, provider payor money)

Front 11

FTC requires what when a drug company buys a PBM and why?

Back 11

firewall b/w the 2 companies; thought that the drug co's would put only its drugs on the formularies

Front 12

Vertical Integration?
Horizontal integration?

Back 12

V)acquiring a co in the distribution channel avove or below your company
H)acquiring a co that is a competitor in the distribution channel

Front 13

Commonly outsourced parts of a PBM (3) and why could these be outsourced?

Back 13

1)claims processing
2)claims processing software
3)pharmacy network development

considered undifferentiated commodities

Front 14

What are the main differentiate items in a PBM? (3 of many)

Back 14

1)FORMULARY
2)clinical management programs
3)member service

Front 15

Using a PBM advantages (3)

Back 15

1)save program development costs
2)eliminate information system development
3)minimize operational expenses

Front 16

Hybrid pharmacy program management? (2)

Back 16

1)HMO builds an internal pharmacy MANAGEMENT program
2)HMO uses a PBM for resource intensive OPERATIONAL services

Front 17

4 basic categories of PBM services?

Back 17

1)administration
2)core operations
3)core program management
4)advanced services

Front 18

Most common services HMOs outsourced to PBMs were (3 in order)

Back 18

1)claims processing
2)POS edits
3)DUR programs

Front 19

Administration (PBM service) includes...(3)

Back 19

1)member benefit info
2)benefit design consultation
3)member eligibility

Front 20

Core Operations (PBM service) includes...(3)

Back 20

1)claims processing
2)POS edits
3)mail service

Front 21

Core Program Management (PBM service) includes...(3)

Back 21

1)member services
2)drug formulary managment
3)pt/MD education

Front 22

Administration (PBM service) includes...(3)

Back 22

1)demand management
2)case management
3)outcomes research

Front 23

Most popular PBM programs used by employer groups are: (3 in order)

Back 23

1)claims processing
2)generic substitution
3)pharmacy network development

Front 24

Basic cost component drivers to a pharmacy benefit (b/w MCO and PBM) (3 of many)

Back 24

1)drug ingredient reimbursement rate
2)utilization rate
3)retail/mail dispensing fee

Front 25

Today most PBM arrangements w/ MCO are ____ contracts which are....

Back 25

Administration Services Only (ASO); PBM agrees to provide management services for a fee but Rx costs are pass thru to the MCO

Front 26

_____ is the most popular and contributing approach to continued growth of PBMs

Back 26

hybrid

Front 27

When contracting for PBM services....should be explored (4)

Back 27

1)benefit design flexibility
2)clinical programs
3)drug formulary for rebates
4)pharmacy network size

Front 28

Major emphasis in today's HC system is....

Back 28

balancing the quality of care w/ the cost of care

Front 29

DUR is intended to ensure...and who came up w/ it?

Back 29

appropriate drug therapy

Brodie

Front 30

3 DUR structural principles from Brodie

Back 30

1)authority derived from an appropriate source
2)availability of existing profiles of drug usage
3)standards of appropriateness against which drug usage can be reviewed

Front 31

Continuous evaluation of DUR =

Back 31

DUE

Front 32

Brodie effect on DUR

Back 32

transformed DUR from simple study of drug usage patterns to a full eval of clinical drug use

Front 33

Pharmacist DUR consists of... (3)

Back 33

1)drug-drug interaxns
2)therapeutic duplication
3)under/over dosing

Front 34

Who uses...
a)MUE
b)DUR
c)DUE

Back 34

a)Joint Commission
b)OBRA
c)NCQA

Front 35

Key processes in DUE/MUE (4)

Back 35

1)prescribing medications
2)preparing medications
3)dispensing medications
4)monitoring efficacy and safety

Front 36

Retrospective DUR
a)def
b)disadv (2)
c)items commonly id'd (3)
d)is commonly done on...

Back 36

a)drug has been administered to pt and is reviewed to determine if that therapy met approved criteria
b)will not have immediate impact on pt care AND relies on written documentation
c)abuse/misuse; drug-drug interactions; incorrect dose
d)paid claims

Front 37

Concurrent DUR
a)adv
b)disadv
c)items commonly id'd (3)

Back 37

a1)can correct actions @ time pt is receiving meds (b/c this is usually done in a hospital)
b)MD must be contacted and discussed
c)drug age precautions; drug-disease CI; drug-drug interactions

Front 38

Prospective DUR
a)adv (2)
b)disadv
c)items commonly id'd (3)

Back 38

a1)done b4 meds given to pt so issues can be resolved b4 drug is given
a2)teaching opportunity for pharmacists
b)difficult to implement
c)abuse/misuse; drug-allergy interaxns; drug-drug interaxns

Front 39

Steps in conducting a DUR (10)

Back 39

1)gain authority and assign reponsibility
2)delineate scope of DUR
3)ID important specific drugs to be monitored and evaluated
4)ID indicators
5)establish thresholds
6)collect and organize data
7)evaluate drug use when thresholds are reached
8)take axns to improve drug use
9)assess effectiveness of axns
10)communicate info to appropriate individuals

Front 40

____ mandated DUR for Medicaid and must consist of...(4)

Back 40

OBRA 1990
1)prospective DUR
2)retrospective DUR
3)application of explicit predetermined criteria
4)educational program

Front 41

Since to introduction of the POS systems; 5 management fxns have arisen for the PBM

Back 41

1)eligibility verification
2)PA for certain drugs
3)claims submission
4)claims adjudication
5)prospective DUR

Front 42

Purpose of a PA?

Back 42

prevent prescribing of certain meds unless defined and specific criteria are first met

Front 43

____ are considered the alerts from the pharmacy's software program

Back 43

Prospective DUR

Front 44

True prospective DUE is to include...

Back 44

prescriber education

Front 45

Academic Detailing? and has been shown to...

Back 45

MD prescribing behavior is altered after 1-on-1 education by doctoral-level trained clinical pharmacists

be the only effective axn to effect prescribing behavior

Front 46

Broad DUR goals (3)

Back 46

1)cost reduction
2)improved quality of care
3)education of providers

Front 47

Pharmaceutical Care def

Back 47

obligation of pharmacist to work w/ pts in conjunction w/ other HC professionals to get desired outcome of drug therapy

Front 48

Therapeutic Drug Outcomes? (4)

Back 48

1)cure of a disease
2)eliminate/reduce pts symptoms
3)slowing of disease process
4)prevention of a disease

Front 49

Monitoring of drug therapy involves...

Back 49

identifying, resolving, and preventing potential and actual drug-related problems

Front 50

Pharmaceutical care pharmacy services include...(3)

Back 50

1)pt counseling
2)PK services
3)drug utilization review

Front 51

Current incr use of pharmaceuticals can be seen b/c of....(3)

Back 51

1)more aggressive treatment of disease
2)more meds to treat diseases
3)people living longer

Front 52

Reasons for incr in medication costs? (3)

Back 52

1)incr in medication use
2)biotech meds
3)incr in drug-related adverse events

Front 53

One of the most important objectives of managed care is ____ which is....

Back 53

seamless HC

no intrusions to optimal HC (nonseamless when formulary won't cover optimal drug)

Front 54

Pharmaceutical care is managed care????

Back 54

b/c goal of pharm care too is to coordiate all HC providers and HC systems to obtain best outcomes for the pt

Front 55

Goal of e-prescribing is...

Back 55

integration of pharmacy, medical and other pt HC data

Front 56

Main barrier to implementing pharmaceutical care is....

Back 56

lack of communication among different HC personnel

Front 57

Pharmaceutical Care activities...(3 of many)

Back 57

1)academic detailing
2)case management
3)disease management

Front 58

Disease Management in HC is a...

Back 58

systemic approach to treating disease states based upon clinical evidence from whole populations and health team outcomes

Front 59

Key components of a Disease Managment Program (3)

Back 59

1)treatment guidelines
2)ability to obtain measurements from clinical parameters
3)pt/provider education

Front 60

Steps to develop a disease management program (9) and main reason these usually don't get going

Back 60

1)administrative and MD commitment
2)ID of a HC team
3)assessement of disease state processes
4)problem ID
5)guideline development
6)data analysis
7)goal setting
8)program implementation
9)program evaluation

lack of step #1, commitment

Front 61

Disease States that are usually part of disease management (3 and 1other thing)

Back 61

1)asthma
2)DM
3)depression

also focuses on beneficial lifestyle changes for these diseases

Front 62

Goal of Guideline development and the first 3 steps

Back 62

DECR variation in physician practices while ensuring appropriate care

1)ID a guideline committee
2)ID time/$ needed to complete task
3)ID who will be using the guidelines

Front 63

Pharmacist managed clinics include... (3)

Back 63

1)anticoag clinics
2)antihyperlipidemia clinics
3)asthma clinics

Front 64

Pharmacist run ADE program is...

Back 64

team of MD's and pharmacists that examine how ADE's are reported in outpt setting and develop better way to incr reporting of ADE's

Front 65

For disease management/pharmaceutical care programs to survive (3)

Back 65

1)incr quality and decr costs must be seen
2)prove that incr quality of care and outcomes
3)incr cost effectiveness

Front 66

_____ is used as a marker for quality of care

Back 66

pt satisfaction

Front 67

Problems w/ pharmcists getting reimbursed for cognitive services (3)

Back 67

1)lack of payment
2)systems not set up to reimburse pharmacists
3)no set standards on appropriate amt of payment for cognitive services

Front 68

Ways cognitive services could be reimbursed is...(3 and jacobs opinion)

Back 68

1)FFS basis
2)capitated payment systems
3)paid for directly by pts
4)DPh should be recognized as medical providers and reimbursed under medical model

Front 69

Calculating the value of Pharmaceutical care is usually done via...

Back 69

cost avoidance; by preventing hospitalizations or medical visits

Front 70

Disease Management def (3)

Back 70

1)pt focused, comprehensive approach to minimize the treatment variability of a specific disease
2)improve pt care outcomes
3)optimize the expenditure of resources

Front 71

Disease management often cooridanted by....
Pharmaceutical care coordinated by...

Back 71

MD
DPh

Front 72

Disease Management programs share.... (5)

Back 72

1)physician-directed care
2)comprehensive care
3)goal-oriented treatment guidelines
4)outcome goals
5)pt education and empowerment

Front 73

Disease Managment offers the opportunity to...

Back 73

measure the economic value of pharmaceuticals and clinical programs

Front 74

Precursor to disease managment (and details)

Back 74

case management in 80s, pts w/ high-cost or complex conditions were targeted; was run by a case manager (usually a nurse)

Front 75

Problem w/ Case Management

Back 75

changed an MD's behavior for 1 pt; did nothing to improve overall behavior of MD's in treating a specific condition

Front 76

Disease Management vendors?

Back 76

they agree to manage treatment for pts w/ specific disease states (carved-out from mainstream HC)

Front 77

Characteristics of medical conditions that are ideal candidates for disease managment...(3)

Back 77

1)chronicity
2)high prevalence and high cost
3)high rate of preventable conditions

Front 78

Key to success of disease management

Back 78

"bench-marking"; it helps plans ID strengths, weankesses and areas of opportunity

Front 79

Feedback loop for program refinement of a Disease Management Program (3)

Back 79

1)execute disease management program
2)measure interim results and refine program
3)measure and report final outcomes (THEN LOOP BACK TO 1)

Front 80

Key for failure of a disease management program is...

Back 80

lack of organizational commitment

Front 81

2 forces have encouraged the growth of disease managment

Back 81

1)growing attention to quality of care delivered by managed care
2)improved ability to integrate data

Front 82

PBM role in disease management (2)

Back 82

1)traditionally they clashed b/c PBM was cost focused NOT outcomes focused
2)PBMs have adjusted focus to use of cost-effective meds which reduce medical HC costs

Front 83

Why did drug manufacturer's disease managment fail? (2)

Back 83

1)ill-conceived
2)thinly veiled marketing programs offered to win formulary acceptance

Front 84

Disease managment programs strategies to achieve "buy-in" of MD's? (2) and will often resist b/c...

Back 84

1)convince them a disease management program will NOT diminish the central role they play in caring for pts
2)program will assist MD's in educating pts

1)viewed as "cook book" medicine

Front 85

Pharmacy "cognitive services" def

Back 85

services provided for a pt or HC professional that are either judgmental or educational in nature

Front 86

Factors explaining slow development of pharmaceutical care practices in the community (2)

Back 86

1)lack of financial reimbursement
2)lack of available time

Front 87

Opportunity of pharmacist in disease management (2)

Back 87

1)meds are a core component of disease management
2)management/use of meds in combo w/ others is a big opportunity

Front 88

3 factors that contribute to the successful ultilization of disease management guidelines

Back 88

1)must be based upon info from credible sources
2)must be realistic
3)must be customized by plan physicians/DPh

Front 89

Many sources of pt treatment guidelines (4)

Back 89

1)Agency for HC policy and research (also communicate/share guidelines)
2)medical associations
3)private disease management companies
4)federally sponsored task forces

Front 90

Customizing Health Plan guidelines means making guidelines that...and ex

Back 90

guidelines that work best for health plans are heavily customized versions of externally prepard guidelines (an OK plan would best include specialist from OU and OSU colleges of medicine)

Front 91

2 most important individuals in disease management are...

Back 91

1)pt's primary MD who coordinates all care
2)pt; who must comply w/ treatment plan

Front 92

Barriers to successful Disease Management programs (2)

Back 92

1)organizational commitment
2)accurate data to measure clinical/economic outcomes

Front 93

Pharmacy carve out is at ____ level; Speciality carve out is at ____

Back 93

PROGRAM LEVEL

disease level

Front 94

Specialty carve out?

Back 94

Pharmacy is carved out of health benefit; then Specialty is carved out of Pharmacy benefit

Front 95

2 ex of Carve-out disease managment

Back 95

1)AIDS: Clinical Partners
2)Rare Diseases: Accordant

Front 96

Performance of disease managment has 4 categories

Back 96

1)cost of all components as well as avoided costs
2)quality of care relevant to the medical condition
3)satisfaction of members and HC professionals
4)health status of members

Front 97

PBM is always a...

Back 97

carved out pharmacy benefit

Front 98

Disease Management will only thrive if...

Back 98

it meets pt needs, it cannot be successful w/o pts active participation