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167 Cards in this Set
- Front
- Back
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What percent of patients receive benefits through a PBM?
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95%
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What are PBMs?
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-Companies that administer drug benefit programs for employers and health insurance carriers
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Who do PBMs contract with?
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MCOs, self-insured employers, insurance companies, Unions, Medicaid
and Medicare managed plans, Federal Employee Health benefits program and other government entities |
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Another definition of PBM
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organizations that apply managed care principals to Rx drug programs to promote optimal, cost-effective use of health care. Manage drug and dispensing cost.
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Who does PBM deal with?
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Patient
Physician Pharmacy Pharmaceutical Manufacturer Employer/Insurer |
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How many major PBMs are there?
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60
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What do the client and PBM determine together?
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what drugs will be covered
member's cost-sharing requirements and pharmacy network access |
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Where do PBMs obtain their revenue from?
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clients, mail-order pharmacies and manufacturers.
Large PBMs set up own mail-order pharmacy increase savings in dispensing and increased revenue |
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How does PBM pass the cost of its payments to pharmacies on to the client
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clients are charged administrative fees for claims processing and basic services
plan member pays required copay or coinsurance |
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How do manufactures ensure they will be included in the PBMs formularies?
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with rebates
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About Rebates?
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must be disclosed to PBM clients
PBM can share rights |
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Other ways PBM earns money
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PBM gets revenue for managing rebate
PBM may receive $ for sale of info Manufacture gives to PBM for clinical services or interventions the support the use of their product |
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Fee-for-Service arragement between PBM and HMOs/employers
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most common
PBM paid for claims processing & retains manufacture-paid admin fees and some % of rebates Client assures all risk for the cost of the drug dispensed |
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Risk Sharing arrangement between PBM and HMOs/employers
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PBM and MCO/employer agree on target per patient per month cost(PMPM). If PMPM is greater than the target cost then PBM will share in the overrun and refund $. otherwise PBM shares in the savings
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Capitation Contracts (PBM-HMO/EMPLOYERS)
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PBM agrees to provide all PC for fixed PMPM
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Possible problems with PBMs
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HMO may refuse to pay for drugs on formulary
Lack of consistency PBMs may have ownership ties with pharmaceutical companies Safeguarding Rx information |
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How PBMs have responded to increasing pharmacy benefit costs
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Contract pricing
Benefit design DURs Drug Selection-formularies, step therapy, and prior authorization (price, utilization, drug mix) |
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Strategies of PBMs
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improving efficiency of business model
utilization control on pt behavior Utilization control on MD behavior Promotion of best practices |
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Manufacturer-PBM relationship
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key to producing savings and often revenes for PBM
rebate revenue ~5-25% on brand name drug spend |
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Pharmacy-PBM relationship
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ability to create contracted pharmacy networks is a key PBM tool
requires additional work for pharmacies Pharmacies can obtain higher compensation from non-PBM customers |
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Pharmacy Reimbursement
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comprised of Average wholesale price and a dispensing fee for the pharmacists services
-there has been a lowering of dispensing fees given over time |
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Why is e-prescribing not catching on?
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expense and lack of reimbursement for adopting a new system.
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What is Rx HUB?
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an electronic exchange that would link physicians, pharmacies, PBMs, and health plans
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Utiliaztion Controls on Patient Behavior
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Co-Payements, tiered pricing programs, drug caps, education
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Drug Plan designs
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estb. to share portion of cost with members
3 or more tier plan used by 75.3% of drug plans most common is 3 tier (generics, preferred brands, non-preferrred brands) |
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Utilization controls on physician behavior
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prior Auths, formularies, therapeutic interchange, DUR, education and drug info, provider profiling, penalties for violating prescribing rules
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Provider profiling
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generating data on MD prescribing and comparing MDs to expected prescribing patterns for select drug categories
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DUR
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monitor for patient specific drug problems through concurrent or retrospective review.
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Formulary Management
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list of drugs classified by therapeutic category or drug class that are considered preferred for a given MCO population
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Therapeutic substitution or interchange
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Interchange of therapeutically equivalent but chemically unique drug in accodance with estb. policies and procedures with in a healthcare system's evidence-based formulary
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Formulary Controls
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while DUR has provided only limited savings historically, generic and therapeutic substitution provides an immediate response by ensuring the use of less expensive agents
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Promotion of best Practices
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Pharmaceutical Care/MTM
Disease Management |
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Buzzwords in Managed Care
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Compliance programs
Disease or health management Case management MTM |
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Disease Management Program
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approach to patient care that coordinates resources across the entire healthcare delivery system and throughout the life cycle of the disease
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Compliance Programs
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Reminder letters or phone calls to patients
Compliance Clubs Notifications to Doc of noncompliant patients referrals to pharmacists and/or case managers for intensive counseling and follow-up programs |
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Drug Safety
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The drug causes no or acceptable harm
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Patient Safety
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Consequences when drugs are used (or not used) according to best evidence
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Critical thinking in pharmacy means:
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To be open to the fact that new drug safety issues may surface and
to evaluate one's own practice constantly against current evidence and make improvements where necessary |
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History of Medicare
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Medicare (1965)-OPT OUT
part a- hospitalization part b- physician visits and some drugs part c- (old HMOs) Medicare Drug Benefit (2003)OPT IN apart of Medicare modernization act medicare part D |
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Quirks in Medicare D system
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True Out of Pocket Costs
some drugs not covered uneven monthly payments over a year formulary variations partners with different plans Small window of enrollment |
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Factors to consider when choosing medicare plan
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Is your drug covered, if so what is cost?
Monthly premium yearly deductible doughnut hole coverage mail service network pharmacy |
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Is it Safe to assume that last year's plan will be the best plan next year?
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NO- re-evaluate plan every year based on your current meds.
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What is an Outcome?
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death rate
hospital length of stay quality of life adverse drug reactions economic outcomes patient satisfaction |
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Key points to take away from why be a pharmacist lecture
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pharmacists can change the outcome of a patient's life in a positive manner
The application of pharmaceutical care can change the course of a patients illness It is your choice to be the pharmacist that you choose to be |
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What are the key features of Quality?
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High quality decision making
high quality performance evidence based medicine patient's preferences |
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How is quality measured?
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Structure
-infrastructure of the pharmacy Process -all aspects of MUP Outcomes -diagnosis, comorbidities |
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Why do we measure?
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-a way to see what is important to you or others
-Indicates Changes -Improvement Opportunities or necessity |
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How can we measure Improved Outcomes?
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Medical measures (BP, blood glucose, ECG)
Patient Measures Economic measures -Do NO economic harm -effective and safe at lowest cost |
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Why should the pharmacy focus on process?
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it works well with standard protocols and credible data may exist
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Indicator development
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Recognizable
Foreseeable Identifiable Controllable |
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Indicator development process
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literature review
delphi pannel operationalization Criterion validation |
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Continuous Quality Improvement
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aka quality management, and total quality control
first- systems approach & identify problems via scientific method second- systematic and continuous process of trying to improve all aspects of the pharmacy |
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CQI cycle
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Plan
Do Check Act -continuous process -learn as you go & change where needed |
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Current issues in CQI
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1. why did change take a quarter of a century?
2. Cigna agrees to revise MD ranking program- patients were directed to cheaper MDs NOT better pysicians 3. Many organizations are now reporting quality data but there is no assurance of their accuracy |
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Remarks on CQI
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-Quality measure is an unstandardize aspect of health care and never accept any measure w/o understanding how it is derived
-Quality measure new to Pharmacy, but here to stay -Working knowledge of CQI is now a core element in medical school |
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What is the chance of a dispensing error happening to a patient?
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1:30 chance for error
1:1000 dangerous error pharmacy: 250 Rxs per day=4 errors pharmacist: 60 new Rx's per day = 2 errors |
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Most frequent errors
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dispensing errors: Wrong Label Instructions
Where the error occured: most in Inspection, then getting drug, lastly order entry |
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Most type of hospital error
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Omission, Improper dosage/#
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Causes of Medication error deaths
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wrong dose, performance, wrong drug, Knowledge (in order from most imp to least imp)
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Causes of dispensing errors
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Work load
Interruptions Drug names (look alike,sound alike) product packaging communication Tech use/misuse drive thru window work flow physical design |
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Attitude Important
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more likely to commit errors when you are dissatisfied with professional, work conditions, staffing, training, time for clinical
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What is the best kind of culture?
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a safety culture, have a forgiving environment, since anxiety of future errors is the number one cause of them
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drawbacks to e-prescribing
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new kinds of errors, Power shifts, dependence, more and new work, workflow, system demands, Commnication, emotions, dependence
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What does JCAHO suggest for patients to do?
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take and active role in your healthcare and ask the physician and the pharmacist a certain set of questions
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Is there a law to apologize without blame?
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YES!!
excludes expressions of sympathy after accidents as proof of liability |
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Which aspect of patient-centered are allows the patient to make decisions regarding their treatment plans?
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Autonomy
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In 1900, the leading cause of death in comparison with today were attributed to:
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more infectious disease and less chronic disease
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The trends in awareness, treatment and control of high blood pressure suggests that?
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-over last several decades less than half of the ppl with HTN were successfully treated
-there has been a steady increase in the percentage of ppl who are aware of their blood pressure -in the last survey (1999-2000) about half of the ppl with HTN were successfully treated -survey demonstrates the need for more effective HTN medications to be devloped |
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The "state of complete physical, mental and social well being and not merely the absence of disease or infirmary" refers to the...
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def of health from the world health organization
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Direct-to-consumer advertising on TV is regulated by
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The FDA
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As a pharmacist, using the "teach back" technique when counseling on a new medication
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Requires having the patient summarize/demonstrate what they understand about the medication that you presented to them
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T/F Health-related quality of life is now one of the outcomes measured in a drug approval process?
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true
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T/F ACPE mandated the PharmD, a six year degree program as the entry level requirement
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True
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Qualities of patient-centered care include
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providers respect patient values
care is coordinated accross different providers Patients are involved in decision making process |
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SHINE would provide MAC with what type of support?
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free instruction and help with Medicare D
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When providers over-treat or over-prescribe b/c health care costs are covered is an example of
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Moral Hazard
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On the Supply-Demand curve, the EQ point refers to:
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When demand equals supply
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At the price point P, quantity supplied is to the right of quantity demanded this means there is a
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Surplus
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If at price P there is a shift in demand to the right, then what is the impact on QD?
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there is an increase in QD
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T/F economics is defined as "the study of how individuals and societies allocate their limited resources in attempts to satisfy their unlimited wants."
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true
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Mac was newly diagnosed with what disease state in Case 2?
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Type II diabetes
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T/F by decreasing patients' out-of-pocket expenses, health insurance has encouraged patients to consume more health services than they would if they were bearing the full cost if the product and service
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True
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What is a characteristic of risk in health insurance?
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Generally measurable
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Payment of health care expenses until a specified amount has been paid out-of-pocket over a period of time
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deductible
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Group policies are
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less expensive than individual insurance
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What federal legislation mandated that pharmacy offer counseling to medicare patients?
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Omnibus Budget Reconciliation Act
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What does Medicare A cover?
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Home health care
skilled nursing facility services Hospice |
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Which type of MCO employes everyone who delivers health care to the plan's patients?
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Staff Model HMO
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T/F Medicaid coverage varies from state to state
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true
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FDA responsibilities include
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Food Drug & Cosmetics
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Advantages of three-tier presription benefits include:
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generic dispensing rate increases
Consumer incentive to choose cost-effective drugs Allows access to open formulary that allows "choice" |
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When looking at the poorest US citizens, the majority of their health related services is funded by:
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medicaid
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Based on World health report 2000 of health measures, the countries ranking lower than the US is
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Germany
Singapore Canada Japan All rank HIGHER than US |
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Which Medicare service is largely financed through payroll tax deductions
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part A
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Stores like Wal-Mart and target are classified as mass merchandisers because
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their primary business is not pharmacy
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how many stores required for a pharmacy chain?
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4 or more
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The vast majority of prescription drug products that are used in the US flow through
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Outpatient Settings
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T/F the drug consumer's mindset and the prescriber's mindset about prescription drug use are usually the same
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False
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US government affords the first manufacture to bring to market a generic version of a medication some market exclusivity. What is the major benefit of this exclusivity?
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6 months exclusive rights to be the only distributor on the market
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Channels of legal distribution of prescription drugs includes:
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Drug wholesaling
Direct from the manufacture |
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A medication that is classified as a blockbuster product must have annual sales of:
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1 billion
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McKesson, Cardinal Health, and Amerisource Bergen account for the majority of drug product sales in the US. These three organizations would be classified as
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primary wholesalers
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the process of relabeling or redefining a personal or social problem as a medical condition is called
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medicalization
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On average, what item has the greatest cost for dispensing a prescription drug in a community pharmacy?
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The drug product
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T/F there are cases where a patient must be injured to obtain a desired therapeutic outcome and so this would not be classified as a drug related morbidity?
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true
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Which program was designed to provide services that will optimize therapeutic outcomes for targeted beneficiaries
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MTM
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A patient with a UTI that is currently on an antibiotic for treatment is still symptomatic after 3 days of continuous treatment. This can be classified as?
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Drug therapy problem
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T/F Drug manufactures can be classified as either a price maker or a price taker
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true
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Any circumstance during therapy that a competent professional would see as inconsistent with the objective of therapy is called
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drug therapy problem
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A person's experience of not being well:
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Illness
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An inference based on interpretation of subjective and objective data, usually from an ill person
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disease
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inability to meet obligations or engage in desired "normal" activities
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Sickness
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Which of these is a highly directed, highly individualized, post graduate program designed to prepare the participant to become an independent researcher?
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Fellowship
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T/F restrictions to access to drugs and of reimbursement tend to be stricter in a closed formulary system
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True
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How have PBMs responded to the increasing pharmacy benefit cost
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Contract pricing
benefit design drug selection utilization management |
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Rebates from drug manufacturers are usually based on a PBMs ability to?
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achieve market share targets for specific medications
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Gatorbait HMO has recently signed a contract with a new PBM, Medical Haven. The contract states that for all patients, Medical Haven will work to keep medication spending to only a 5% increase in spending over last year. Anything above the 5% increase will be paid for by Medical Haven and not by Gatorbait. This type of contractual relationship is called?
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Risk Sharing
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PBMs make money from these sources:
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rebates from manufacturers
fees from prescription claims processing sale of data containing patient prescription use |
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Who is the new player now involved in paying for prescription medications that he had not included on his slide?
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medicare
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T/F not only do the majority of employers offer access to mail order pharmacies but there are some that require certain medications to be dispensed by a mail order service
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true
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T/F Literature suggests that one of the best ways to improve patient care and reduce overall health care costs is to implement formularies to help health care providers determine what medications to prescribe
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false
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T/F the most popular type of contractual relationship between PBMs and HMOs are capitation contracts
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False
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JCAHO found that for most sentinel events the root cause could be attributed to
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Communicaton
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According to Dr. Winterstein the following are true in the regards to dug safety
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-Before the thalidomide disaster rug companies did not have to prove drug efficacy
-shands was one of the first instutions to implement a drug monitoring system |
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According to Dr. Winerstein, this is true about patient safety:
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-drug safety address the drug causing harm. We assume that drugs are safe when they are approved but they have side effects
-patient's safety has to do with medical error, patients may be exposed to harm because providers make errors such as using the drug in an inappropriate fashion |
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T/F in Florida if a health care professional apologizes for any type of mistake that apology can be used as proof of liability in the committing the error
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false
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T/F preclinical toxicity testing of medications introduced in the 1938 Food and drug cosmetic act referred to testing of medication toxicity on animals before testing on humans
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true
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How many drug plans are there in florida?
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54
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How many MA-PD plans are there in alachua?
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15
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The following statements are true regarding medicare part D?
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it is a government program that contracts with private insurance carriers to offer it's consumers choice and competition
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T/F Flynn & Barker showed that when looking at Automation in community pharmacies the effects on errors in the pharmacy was always reduced no matter the setting?
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False
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T/F There are several advantages to being a community pharmacist one being the strong interpersonal relationships that you build with your patients
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True
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T/F some pharmacists are skeptical about the impact pharmacists can make upon a patient's outcome
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True
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Pharmacists can be replaced by dispensing machines
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True
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When a patient with Medicare part D hits the "donut hole" in their coverage how much will they be paying for medications out of pocket?
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100%
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who is most trusted when it comes to drug information?
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Doctor
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What are Customers most concerned with when it comes to non-prescription services?
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1. pricing and insurance
2. professional services 3. convenience |
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What are customers not concerned with with non-dispensing services?
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flu-shots, BP screening, diabetes counseling etc.
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OBRA-90
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federal endorsement of patient counseling
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What are RPh's expected to do?
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-review medication orders for interactions and appropriateness
-document any actions that were taken -prevent medication errors -ensure they follow through with changes that are needed |
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Credentialing
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action by which an agency attests to an individual's ability to meet a set of standards
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Requirements to be a licensed pharmacist are:
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have:
PharmD NAPLEX MPJE medical errors course |
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Are internship hours required to be a licensed pharmacist?
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NO
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Consultant RPh:
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RPh's who are paid to provide expert advice on the use of medications by individuals or w/in institutions, or on the provision of pharmacy services institutions
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Do consultant RPh's require postgraduate training?
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yes
residencies fellowships board certification other cert programs M.S./PhD Clinical Scientists |
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Residencies
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organized, directed post-grad training in a defined area of practice
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Fellowships
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directed, highly individualized post-grad program designed to prepare someone to be an independent researcher
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Certification
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recognition by a nongovernment agency that an individual has completed predetermined qualifications in a field of specialized knowledge
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Five specialties of Certification:
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oncology
psychiatric nutrition support nuclear pharmacotherapy |
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What is recommended if interested in a career in academia, industry, or govt research?
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M.S./PhD
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What are Managed Care Strategies intended to do?
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improve the quality of medicine use and to reduce preventable drug related morbidity (PDRM)
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1937
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more than 100 ppl died from sulfonilimide elixer in diethylene glycol
-1938 food drug and cosmetic act requires preclinical testing |
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1950's
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relationship between chloramphenicol and aplastic anemia
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1960's
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FDA sponsors hospital-based drug monitoring programs
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1961
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Thalidomide disaster, kefauver-Harris act requires studies for drug safety and efficacy programs
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Black Box warning
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put on patient leaflets to alert that drug can't be used with something else, presents new info that manufacturer was not aware of when drug was approved
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National Drug Safety Mechanism
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1. Pre-Clinical studies
2. Pre-marketing clinical studies 3. Spontaneous Reporting 4. Post-marketing studies |
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Examples of medical error
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slips and lapses
suboptimal care errors of omission errors of comission |
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Professionalism
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A set of attitudes and behaviors believed to be appropriate to a particular occupation
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Drug Information
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Providing accurate, unbiased, factual information or consultations in response to pharmacotherapy problems received from health care professionals and consumers
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Primary Literature
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journal articles
periodical articles studies that present new info on drugs or diseases -peer review ensures quality of the articles |
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Secondary literature
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Road map to primary literature
-includes indexing and abstracting services -gives you a headline of what the article is about -but not full article (misleading) ex: pubmed, clin pharm |
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Tertiary literature
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general references
includes textbooks electronic references |
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Randomized controlled trials
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highest level of research
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evidenced based medicine:
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A methodology for evaluating the validity of research in clinical medicine and applying the results to the care of individual patients
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Cross-Sectional/Case Control
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Ex: look at cancer patients and see if they smoke
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Cohort
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Ex: look at ppl taking a drug over a certain amt of time and see outcome, how many ppl develop breast cancer and how many do not
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