Iphc Mid-Term

Front 1

Patient Centered Care

Back 1

Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions

Front 2

Care provided patients should preserve their dignity and autonomy.

Back 2

1. maintain self-respect

2. feel valued as a person

3. acknowledge and encourage patient control of decision making regarding their health care.

Front 3

Dignitity threatened by

Back 3

Insensitivity of providers to the needs and feelings of patients.

Front 4

Autonomy is threatened when

Back 4

Patients do not fully understand their treatment or alternatives and are not actively involved in the decision-making process

Front 5

Why is Patient center care important for Pharmacist?

Back 5

1. Most medical treatments are for chronic conditions; patients and caregivers do more to manage therapy than any health care provider

2. Patients have questions about drug therapy that they do not ask

3. Patients make autonomous decisions about their use of medications

4.Patients often do not understand medication instructions

(IOM)

Front 6

Health Belief Model:

Back 6

A health behavior theory that describes the likelihood an individual will take action to change a behavior

Front 7

Components of Health Belief Model

Back 7

1. susceptibility and severity of disease

2. perceived benefits and barriers

3. cues to action

4. self-efficiency

5. demographic, sociopsycological, and structural variables

Front 8

Components of Health Belief Model Flow Chart

Back 8

.

Front 9

For patients to change their behaviors:

Back 9

They must perceive the benefit of the change to be greater than the barriers to overcome it or they must believe that they are very susceptible to that disease causing them fear and thus a change in behavior to prevent the disease. If the barriers are perceived to be greater than the benefit or the person does not think it likely to get the disease, than person will not change their behavior. The person must also believe in his/her ability to overcome the barriers in order to reach the goal.

Front 10

Patient empowerment (4 parts)
1-3 suggested by JCAHO

Back 10

1. Understand that more tests or medications may not always be better. Ask your doctor what a new lab test or medication is likely to achieve.

2. When your doctor writes you a prescription, make sure you can read it. If you can’t read your doctor’s handwriting, your pharmacist might not be able to either.

Front 11

Patient empowerment (cont)

Back 11

3. If you do not recognize a medication, verify that it is for you. Ask about oral medications before swallowing, and read the contents of bags of intravenous (IV) fluids.

4. Purpose is to encourage patients to get involved in their own healthcare and be aware of alternatives. This helps the patient avoid medical error.

Front 12

Important communication skills of healthcare professional:

Back 12

1. Empathetic listening and understanding (verbal and nonverbal)

2. Genuineness

3. Respect for the patient

Front 13

Empathetic listening and understanding (verbal and nonverbal)

Back 13

i) is perceived by patients as evidence of caring and concern

ii) contributes to a patient’s sense of worth and dignity

iii) encourages patients to share concerns or confusion

iv) facilitates patient’s own problem-solving

Front 14

Genuineness

Back 14

i) The patient must perceive you as honest in your communication.

ii) Saying a reflection of feeling statement but nonverbally showing distraction, impatience or annoyance will NOT be experienced as empathy.

Front 15

Respect for the patient

Back 15

i) One of the biggest barriers to effective communication is our tendency to judge the other person.

ii) Patients who feel they might be judged (non-compliant, unmotivated, drug-seeking) will not reveal the problems they have with therapy.

Front 16

Convey empathy to a patient by:

Back 16

1. Nonverbal behavior is as important as words spoken

2.You must genuinely want to listen to and help the patient

3. You must perceive empathic listening as helpful in itself

Front 17

Appropriate listening behaviors:

Back 17

a) Looking at the patient

b) Not crossing your arms

c) Leaning in towards the patient

d) Do not look at watch or seem impatient for conversation to end

e) Take patient away from distractions and to a private area where they feel free to talk

Front 18

Empathetic Response

Back 18

i) Reflection of feeling responses tend to be perceived by patients as understanding and nonjudgmental.

ii) Rephrases very briefly what you understand the patient is feeling based on what he/she has told you.

iii) Does not try to change the person’s feeling

iv) Does not try to stop the person from feeling a certain way

v) Does not judge or evaluate feeling

vi) Simply tries to convey understanding

Front 19

Steps for an effective interview

Back 19

1. Opening the interview
2. Assess current drug therapy
3. Asses each medication in order to assess purpose of drugs
4. Assess ACTUAL use of medications using open-ended questions

Front 20

Steps for an effective interview (cont)

Back 20

5. Assess effectiveness
6. Assess problems
7. Assess allergies
8. Ending interview

Front 21

Opening the interview

Back 21

1. Introduce yourself

2. Identify patient or caregiver by name

3. Explain purpose of interview

4. how it can help the patient

Front 22

Assess current drug therapy

Back 22

1. Establish complete listing -- Rx, OTC, alternative medicine

2. Begin information gathering by asking OPEN-ENDED QUESTIONS—get patients to describe their understanding rather than answer “yes/no” questions

Front 23

Asses each medication in order to assess purpose of drugs

Back 23

What did the doctor tell you this medication was for?

Front 24

Assess ACTUAL use of medications using open-ended questions.

Back 24

Also want to assess difficulties in taking prescribed medicines and do not be mad at patient for not taking medicine.

Front 25

Assess effectiveness

Back 25

1. “How well does the medicine seem to be working?”

2. What are the goals for treatment?

3. How is effectiveness being evaluated? By patient? By physician?

Front 26

Assess problems

Back 26

1. Begin with general question
“What problems have you experienced with your medication?”

2. Follow-up with specific questions on adverse effects
“Have you noticed any new symptoms since you started taking this medicine?”

Front 27

Assess allergies

Back 27

Note allergies to meds

Front 28

Ending interview

Back 28

1. Ask if patient has additional questions or concerns

2. Make yourself available if patient thinks of other information or has questions or concerns about any medication.

Front 29

Important interview tips

Back 29

1. Make sure interview is organized and you flow from one point to the next

2. Make sure you complete finish a point before you move on; don’t come back to the point later; it will confuse patient.

3. Give notice of topic that you will be addressing next

4. Summarize key points before moving on

5. Be flexible and respond to issues as patient raises them; don’t tell the patient to hold the question till later in the interview.

Front 30

Challenges in communication (2)

Back 30

1. Patient not feeling comfortable to discuss their medication problems surrounded by other people. Solution is to take them to a private room or corner away from everyone else and to talk in a quiet voice to insure privacy.

Front 31

Challenges in comunication (cont)

Back 31

Assuring patient understanding (that the patient actually heard and understood what you have said to them; that they can apply the information to their life): solution is the “Tech Back” Technique

Front 32

"Tech Back” Technique

Back 32

1. Ask patient to summarize information presented

2. Ask patients to demonstrate administration

3. Put “blame” for possible misunderstandings on yourself (“I want to make sure I did a good job of explaining about your new medications. Would you summarize the important points to remember about this medicine.”)

4. Allows you to verify understanding, fill in gaps, and correct misunderstandings

Front 33

Low health literacy (reading and understanding the words used by healthcare providers-aka health jargon):

Back 33

Solution is to use “living room: language that everyone understands to avoid making the patient feel stupid and out of place.

Front 34

Element of chronic care

Back 34

1. Health System
2. Delivery System Design
3. Decision Support
4. Clinical Information Systems
5. Self-Management Support
6. Community
7. Patient center because all of the health care providers are working and communicating together in order to have the best outcome for the patient.

Front 35

Element of chronic care
#7 cont

Back 35

i) Ensure regular follow-up by the care team

ii) Give care that patients understand and is consistent with their preferences and values

Front 36

Multidisciplinary Care

Back 36

i) many different professionals work for the good of the patient, although somewhat independently

ii) What happens to people who go to see their doctor, are given a prescription, go to a pharmacy to get it filled, but the pharmacist never talks with the doctor who wrote the prescription. Both people though are trying to help person.

Front 37

Interdisciplinary Care

Back 37

i) Many different professionals work for the good of the patient, COMMUNICATING EFFECTIVELY AMONG THEMSELVES AND WITH THE PATIENT

ii) How it is supposed to work in a hospital and the idea behind a medical home.

Front 38

5 professions involved in a Medical home

Back 38

a) Pharmacist
b) Physician
c) Nurse
d) Physical Therapist
e) Social Worker

Front 39

Medical Home is defined as

Back 39

an approach to providing comprehensive primary care... that facilitates partnerships between individual patients, and their personal Providers, and when appropriate, the patient’s family". The provision of medical homes may allow better access to health care, increase satisfaction with care, and improve health elements

Front 40

Medical Home (cont)

Back 40

a) Assessment
b) Self-management support
c) Care coordination
d) Health literacy
e) Practice coaching
f) Collaborative
g) Support for Medical Home: Patients reap the benefits of more eyes and ears, the insights of different bodies of knowledge, and a wider range of skills

Front 41

Developments that will affect health care system

Back 41

a) Health care reform

b) No “pre-existing conditions” clause for children

c) Children of family plan through age 26

d) Removal of lifetime caps (max coverage offered by insurance)

e) Preventive services with no co-payments

Front 42

3 historical events that shaped our health care system

Back 42

1. Congress passed the Hill-Burton Act and greatly increased the number of hospital beds by providing funds to build new hospitals. The only way to receive this money was to agree to take care of all people who came to the hospital even if they could not pay for the services.

Front 43

3 historical events that shaped our health care system (cont)

Back 43

2. Congress created financial incentives to encourage the education of more and more health care professionals.

3. Congress established Medicare (elderly) and Medicaid (poor) to improve access for the elderly and the poor in 1965.

Front 44

What is an HMO?

Back 44

Health Maintenance Org.

A type of managed care organization (MCO) that shares risk with a network of health care provider of requiring that the providers assume some rick, either directly or indirectly, and that generally does not provide coverage for medical care that is received outside the network.

Front 45

Risk arrangement of HMO's

Back 45

(1) Capitation-providers are paid a fixed amount each month for each enrolled patient, regardless of the amount of health care service actually provided.

(2) Risk pool-an arrangement in which an HMO places a portion of payments in a pool as a source for any subsequent claims that exceed projections, with the providers and the HMO sharing in the surplus (or loss) at the end of the year.

Front 46

Gatekeeper & HMO's

Back 46

Gatekeeper is a central component of most HMOs in which primary care physicians must coordinate and authorize all medical services, including labs, referrals, and hospitalizations. Must receive referral in order for service to be covered by HMO. Helps to limit unnecessary and often expensive referrals to specialists.

Front 47

What is JCAHO?

Back 47

Joint Commission of Accreditation of Healthcare Organizations

i) A nonprofit organization that sets standards of practice for, evaluates and accredits more than 15,000 health care organizations and programs in US.

ii) This accreditation is required to in order to receive reimbursement for Medicare and Medicaid programs.

Front 48

What is DRG?

Back 48

Diagnosis-Related Group

i) A categorization of diseases of conditions created initially by the federal government as a means to reimburse hospitals prospectively for services provided to patients.

ii) How hospitals and other care providers bill insurance companies.

Front 49

Hospital classification

Back 49

1. Federal Govt
2. Non-Federal Govt
3. Non-Govt

Front 50

Federal Government Hospitals

Back 50

aka public hospitals— serve veteran, military personnel, and Native Americans populations.

Front 51

Non-Federal Govt Hospitals

Back 51

aka public hospitals—hospitals owned and operated by city, county or state governments.

Front 52

Non Government Hospitals

Back 52

1. not-for-profit—reinvest finical surplus at the end of the year into the organization (new equipment, remodeling, or new buildings)
2. Investor owned for profit—reinvest financial surplus at end of the year into the organization plus gives some money to the investors in the form of dividends.

Front 53

Type of Service Hospitals

Back 53

i) General hospitals—provide a variety of services including general medical and surgical services

ii) Specialty hospitals—concentrate on one disease process or on one segment of the population.

Front 54

Hospital length of stay

Back 54

i) Acute care (or short term hospital)—have an average stay of fewer than 30 days

ii) Long-term hospitals—have an average stay of greater than 30 days.

Front 55

What is Medicare?

Back 55

Medicare is funded by the federal government and therefore the requirements and benefits are the same throughout the country. It is funded by Federal trust funds. Part D plan (PDP) began in 2006. For disabled and persons over age 65.

Front 56

Medicare:

Type A
Type B
Type C

Back 56

Part A hospitalizations

Part B Physician services

Part C MCO option

Front 57

What is Medicad?

Back 57

Medicaid is administered by each state and receives financial support from the federal and state governments. For persons of low income.

Front 58

Federal portion of Medicad

Back 58

iFederal portion > 50% but varies annually by state

(1) Based on average income relative to national average

(2) Historically in Florida, 55-60% Federal funds

(3) “Enhanced match” in Florida 2009 & 2010 to 66.7%

Front 59

Medicad Eligibility

Back 59

Eligibility: Department of Child and Families

Program Planning and Operations: Agency for HealthCare Administration (AHCA) Division of Medicaid Services

Front 60

Definition difference of Medicare VS Medicad

Back 60

Medicare is only federal government. Medicaid is run by each state but receives some funding from the federal government.

Front 61

Who is eligible for Medicare benefits?

Back 61

(1) Over AGE 65: citizen; employed 10yrs or spouse

(2) Permanent disability payments from Social Security

(3) End-stage renal disease (ESRD)

(4)ALS (“Lou Gehrig’s Disease”)

Front 62

Medicare Part A Specifics

Back 62

(1)Deductibles and co-payments

(2) Acute Care – 90 days medically-necessary per benefit period with 60 days lifetime reserve (190 days lifetime limit for inpatient psychiatric care)

(3) Skilled Nursing Facility – 100 days per benefit period, preceded by > 3 hospital days within last 30 days

Front 63

Medicare Part B Specifics

Back 63

(1)covers outpatient care (e.g., chemotherapy), preventive services (e.g., vaccinations), Durable Medical Equipment (DME)

(2) NOT Covered: dental care; hearing aids; vision care; routine annual physical exam

(3) 20% co-payment for covered services; otherwise 100%

(4) Assignment: physician agrees to accept Medicare payment

(5) Balanced billing allowed up to 115% approved charge

Front 64

Medicare Part C Specifics

Back 64

Managed Care Option –

Medicare Advantage Implications for Seniors based on history & negative experience

Front 65

Medicare Coverage For Most Americans

Back 65

Medicare covers about 45% of care on average; Most beneficiaries have additional coverage

(1) Employer sponsored benefit for retirees

(2) Medigap: private plan for charges not covered by Medicare

(3) 12 plan types allowed (Plans A-L)

(4) Standardized format, language and definitions

(5) Medicaid – Dual Eligibles

Front 66

Medicad - Categorically Needy

Back 66

(a) Families below income/asset threshold–state determines
(b) Child deprived of parental support
(c) Persons receiving Social Security Income (SSI)
(d) Pregnant women and children under 6 below income threshold
(e) Children < 18 below federal poverty level
(f) Qualified Medicare Beneficiaries below specified income and asset thresholds

Front 67

Medicad Categorically needy optional (determined by each state)

Back 67

a) Persons no meeting mandated requirement but sharing characteristics of mandated groups

(b) Must receive same benefits as categorically needy

Front 68

Medicad Medically Needy

Back 68

(a) Optional as determined by states
(b) Higher income threshold minors and pregnant women
(c) Persons with “extra-ordinary” medical expenses
(d) Prenatal and delivery care
(e) Ambulatory care for persons < 18 years old and those entitled to institutional care
(f) Home health services for nursing home qualified

Front 69

Medicad Required Services

Back 69

(a) Inpatient hospital
(b) Outpatient hospital
(c) Physician services
(d) Labs & X-rays
(e) Nursing facilities
(f) Home health
(g) Pre-natal care, family planning
(h) EPSDT
(i) Rural clinics, etc.

Front 70

Medicad Optional Services

Back 70

(a) Outpatient prescription drugs
(b) Physical/rehabilitation therapy
(c) Optometrist and eyeglasses
(d) Prosthetic devices
(e) Home & community-based svcs
(f) Intermediate care for developmental disabilities
(g) Transportation

Front 71

Children’s Health Insurance Program (CHIP)--Reauthorization Act 2009

Back 71

(a) FACT: almost ¾ of uninsured children live in households below 200% of poverty with an adult working

(b) Allows for expansion of Medicaid-type services to low-income children with no health insurance

(c) (200% of poverty in Florida or $44,000)

Front 72

Children’s Health Insurance Program (CHIP)--Reauthorization Act 2009 (CONT)

Back 72

(d) State sets premiums and cost sharing on a sliding scale

(e) An estimated 5 million children eligible but not enrolled

(f) Recovery Act funds have extended programs and funds

Front 73

Penalty for no Medicare Pt D Coverage

Back 73

Part D: Don’t Sign Up - Face Penalty Later. If you sign up later, you pay 1% in premiums more each month you wait after being eligible for Medicare. You will pay this increased premium for the rest of your life. This stops people from only getting Part D when they have to buy expensive medications (adverse selection)

Front 74

Medicare Pt D Open Enrollment Dates

Back 74

Nov 15 to Dec 15

Front 75

When NO Pt D penalty is given

Back 75

Credible coverage is an acceptable alternative: E.g., coverage from VA or former employee benefits that meet or exceed the requirements of Medicare Part. If you have a credible coverage, you will not face penalty charge when you say up for Plan D when your supplement drug plan runs out.

Front 76

Rules for Part D

Back 76

a) Formulary
Some drugs not covered

b) Financial Incentives
copays and deductibles

Prior Authorization
meet certain criteria before prescribing

Front 77

Rules for Part D
(CONT)

Back 77

d) Step Care
Oldest cheapest before newest more expensive

e) Quantity limits
How much of a drug you can receive at one time.

Front 78

Prerequisites of Insurance

Back 78

a) Known peril with predictable frequency

b) Peril occurs at random among individuals

c) Losses are accidental

d)Losses are substantial

e) Losses are determinate

f) Policy holder has an insurable interest

Front 79

Prepaid prescriptions are inconsistent with this principle

Back 79

a) Substantial loss?
i) Consider administrative cost of plan relative to loss

b) Unpredictable?
i) “EVERYONE” uses prescription drugs
ii) Use can be predicted

c) Random? Accidental?
i) Consumer demand for non-essential services
ii) Consumers purchase more costly alternatives

d) Prescription therapies can be preventive
i) Reduce or delay need for more costly expenses

Front 80

Problem: Catastrophic Hazards

Back 80

Soln:
Coverage limits- max amount that person can receive when they receive medical attention

Front 81

Problem: Adverse Selection- only sick people join and not healthy people

Back 81

Soln:
Group policies- businesses that offer insurance and everyone has to join that insurance plan

Elimination Period- waiting period after joining insurance before you can receive benefits.

Front 82

Problem: Moral Hazard- gain from apparent loss

Back 82

Soln
Coordination of benefits- only 1 insurance will pay at a time if you have multiple insurances

Front 83

Problem: Induced demand-used too much

Back 83

Soln:
Cost sharing-patient share the medical cost with the insurance company. Examples include copayments and co-insurance.

Front 84

Differences

Back 84

a) Fee-for-Service (FFS): reimbursement tin which a fee is paid to a provider for each service performed. FFS was the predominate reimbursement mechanism before managed care. Provide incentives to increase the quantity of services provided.

b) Capitation reimbursement: providers are paid a fixed amount each month for each enrolled patient, regardless of the amount of health care service actually provided.

Front 85

Pharmacy Benefit Management (PBM)

Back 85

a)Represent the third party payer

b)Assume responsibility for
i) Benefit design
ii) Controlling cost
iii) Computerized decision support tools
iv) Communication with providers and beneficiaries
v) Agreements with Participating Pharmacies
vi) Mail order options
vii) Utilization review/Auditing providers

Front 86

Cost Containment

Back 86

a) Formularies: The drugs approved for use in a hospital or for reimbursement. Prevents expensive and unnecessary drugs from being charged to the insurance.

b) Cost-Sharing: patient share the medical cost with the insurance company. Examples are co-payments, deductibles, out-of-pocket, co-insurance, and max benefits.

c) Tiered co-payments: a type of patient cost sharing that specifies multiple co-payment level that are designed to encourage the use of preferred drug products, such as generics and lower-cost brand name drugs. Patients pay a higher co-pay for more expensive drugs that are in the higher tier.

Front 87

Cost Containment

(CONT)

Back 87

d) Quantity limit: patient can only get a month supply of their medicine every month

e) Prior authorization: Patient must receive written documentation that that brand of medicine is medically necessary, submit it to the insurance and then insurance will choose whether to authorize or give a reason for refusal. If insurance authorizes the medicine, they will cover some of the cost.

f) Step Therapy: To treat a condition, patient starts at the most cost-effective and safest drug therapy/medicine and then, if the therapy/medication doesn’t work, moves up to a more expensive therapy/medicine.

Front 88

Tiered Formulary:

Back 88

Drugs on a formulary are usually grouped into tiers, and your co-payment is determined by the tier that your medication is on. A typical drug formulary includes three tiers. . .

Front 89

Tier 1

Back 89

lowest co-payment and usually includes generic medications.

Front 90

Tier 2

Back 90

higher co-payment than tier 1 and usually includes preferred brand name medications

Front 91

Tier 3

Back 91

has the highest co-payment and usually includes non-preferred brand name medications.

Front 92

Preferred drug list

Back 92

includes prescription drugs generally covered under the prescription drug benefit plan subject to applicable limits and conditions.

Front 93

Generic Substitution

Back 93

a pharmacist-initiated act by which a different brand or an unbranded drug product is dispensed instead of a drug brand that was prescribed by the physician. This means substituting the same chemical entity in the same dosage form for one marketed by a different company.

Front 94

Therapeutic Substitution

Back 94

a pharmacist-initiated act by which a pharmaceutical or therapeutic alternate for the physician-prescribed drug is dispensed without consulting the physician. This denotes replacement of the prescribed drug with a chemically different drug within the same therapeutic category (eg, hydrochlorothiazide for furosemide; ranitidine for cimetidine; chloramphenicol for erythromycin).

Front 95

Drug Utilization Review (DUG)

Back 95

The review of physician prescribing, pharmacist dispensing and patient use of drugs with the goal of ensuring that drugs are used appropriately, safely, and effectively. Cost containment mechanism as well.

Front 96

Medication Therapy Management (MTM)

Back 96

A broad range of activities within the scope of practice of pharmacists and other quality health care providers intended to insure that patients with multiple diseases and on many medications get the greatest benefit possible from their medication regimen.

Front 97

Pharmacy Benefit Manager (PBM)

Back 97

a specialized company that adjudicates prescription drug claims and manages the prescription drug coverage for a third-party payer by containing costs and influencing the quality of services provided.

Front 98

Major Responsibility of PBM

Back 98

(1)Communication between providers and beneficiaries

(2)Agreements with participation pharmacies

(3)Monitoring of doctor prescription writing

Front 99

Fiscal Intermediary (FI)

Back 99

an organization that facilities exchanges between health care payers and health care providers by underwriting and/or administering health care benefit programs. Most often are private insurance companies that serve as the federal government's agents in the administration of the Medicare program, including the payment of claims.

Front 100

Third Party Administration (TPA)

Back 100

an organization that processes insurance claims or certain aspects of employee benefit plans for a separate entity.[1] This can be viewed as "outsourcing" the administration of the claims processing, since the TPA is performing a task traditionally handled by the company providing the insurance or the company itself. Often, in the case of insurance claims, a TPA handles the claims processing for an employer that self-insures its employees. Thus, the employer is acting as an insurance company and underwrites the risk. The risk of loss remains with the employer, and not with the TPA.

Front 101

Activities carried out by the PBM

Back 101

a)Benefit design
b)Controlling cost (aka negotiating lower prices with the manufacturer)
c)Computerizing decision support tool
d)Communication with providers and beneficiaries
e)Agreements with participating pharmacies
f)Mail order options
g)Utilization of review/auditing providers

Front 102

U&C

Back 102

Usual and customary charge. Refers to customers that are paying cash for their prescription. Cost to cash patient (pharmacy retail price) = cost of drug product + dispensing fee (service charge)

Front 103

AWP

Back 103

Average Wholesale Price. AWP is what the pharmacy pays for the drug.

Front 104

AMP

Back 104

Average Manufacturers Price. AMP is what wholesalers and large hospitals or chain pharmacies will pay for the drug. AMP<AWP

Front 105

WAC

Back 105

Wholesale Acquisition Cost. WAC is the price sold to wholesalers (is based on survey of wholesale pricing data rather than manufacturers’ list prices).

Front 106

AAC

Back 106

Actual Acquisition Cost. AAC is the actual selling price of the drug to customers

Front 107

EAC

Back 107

Estimates Acquisition Cost. Third party payers recognize that a pharmacy’s AAC is less than AWP and therefore don’t want to repay AWP. EAC is the standard set in palce instead of AWP = AWP – x% or WAC + x%.. EAC could also = MAC.

Front 108

MAC

Back 108

Maximum Allowable Cost. MAC is the amount paid by PBM for the drug ingredient cost for a multiple-source drug. MAC is usually set at the price of a low-cost generic product without regard as to whether a brand-name or generic product is actually dispensed.

Front 109

FUL

Back 109

Federal Upper Limit. FUL is same thing as MAC but just what the government uses.

Front 110

Determination of value

Back 110

a)Cost-effectivness

b)Comparative effectiveness

Front 111

Cost-effectivness Pros

Back 111

(1)Greater efficiency

(2)Improved quality

(3)Better patient outcomes

(4)Less variability in provision of care

Front 112

Cost-effectivness Cons

Back 112

(1)Lack of knowledge—incmplete models

(2)Inherent uncertainty—requires analytical assumptions

(3)Lack of transparency due to complexity

(4)Whose interests/perspective are represented? (patient, payer, health system, society, etc…)

(5)Economic analysis leads to rationing—death panels

Front 113

Comparative effectiveness Purpose

Back 113

to inform patients, providers, and decision-makers responding to their expressed needs, which interventions are most effective for which patients under (which) specific circumstances.

Front 114

Interventions os Comparative effectiveness may include

Back 114

(a)Medications, procedures, medical and assistive devices and technologies

(b)Behavioral change strategies

(c)Delivery system interventions

Front 115

American Recover and Reinvestment Act of 2009

Back 115

gave $1.1 Billion for comparative effectiveness research.

Front 116

Results not to be used to. . .

Back 116

(1)Mandate coverage

(2)Establish reimbursement

(3)Set policies for public or private payers

Front 117

Cons of Comparative effectiveness

Back 117

(1)Afraid that research may be used by insurers to deny coverage for more expensive treatments or to ration care

(2)Time and money required for all the research

(3)Timeliness of results

(4)Availabilty of knowledge personnel (without conflict of interest) to conduct research

Front 118

Pharmaceutical Purchasers

Back 118

a) Large volume purchasers

b) Small volume purchasers

Front 119

Large volume purchasers

Back 119

SET OWN PRICE
pharmacy chains, mass merchandisers
government programs: VA, DoD, HIS, Medicaid

Front 120

Small volume purchasers

Back 120

form, aggregations, buying groups or purchasing cooperatives

Front 121

Buying groups/Purchasing Co-ops

Back 121

aggregations of small volume purchasers that come together to buy in bulk making it possible to set own price.

Front 122

IPC

Back 122

Independent Pharmacy Cooperative. 4000 stores that purchase together and agree what brand/generic they will buy.

Front 123

Patient Empowerment Initiatives

Back 123

JCAHO- "Speak Up: Help Prevent Errors in your Care

AHQR: "20 Tips to Help Prevent Medical Errors"

Institute for Safe Medication Practice- "Safe Medicine- Protect yourself from medication error"

Front 124

NIH Study

Back 124

provider-patient communication related to pain management in cancer care.

Front 125

Delivery System Design

Back 125

define rolls, distribute tasks, plan interactions to support evidenced based care, case management services for complex patients, ensure follow-up, give care that is understood by patient and consistent with prefrences and value

Front 126

Unique rolls of professions involved in a medical home.
(Dr. Jeff)
EX. CHF

Back 126

Pharmacist-alert to drug-drug interactions

Physician- discuss ejection fractions and unloading of heart

Dietician- control salt intake

Front 127

Unique rolls of professions involved in a medical home.
(Dr. Jeff)
EX. CHF

Back 127

PT- Cardiac rehabilitation

Social Worker- discuss impact of limited exercise intolerance on social interactions and self image.

Front 128

Retail pricing for prescriptions

Back 128

Cost of Product + Dispensing Fee = Total Rx Charge

Front 129

Community Pharmacy Expenses

Back 129

Products – Inventory

Labor

Pharmacists

Support staff

Expenses Directly Related to Pharmacy Dept

Expenses Shared across all departments within the retail unit

Front 130

Price Makers

Back 130

Free to set price

Constrained by competitors

Manufacturers; Wholesalers;

Insurance Firms

Front 131

Price Takers

Back 131

Accept price offered

Manufacturers in countries with price controls

Dispensing Pharmacies

Front 132

Large Volume Purchasers

Back 132

Pharmacy Chains; Mass Merchandisers

Government Programs: VA, DoD, HIS, Medicaid

Front 133

Large Volume Negotiators

Back 133

PBMs

Front 134

Aggregations of Small Volume Purchasers

Back 134

Purchasing Cooperatives;

Buying Groups

Franchises

Front 135

Revenue captured by institution

Back 135

Fee for Service System:

Revenue increases as number of products and services increases.
Pharmacy Department as revenue generator

Fixed Payment Systems
Revenue fixed; costs increase as products and services increase.
Pharmacy Department as cost center