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180 Cards in this Set
- Front
- Back
providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.
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Patient Centered Care
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______ is threatened by insensitivity of providers to the needs and feelings of patients.
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Dignity
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______ is threatened when
patients do not fully understand their treatment or alternatives and are not actively involved in the decision-making process. |
Autonomy
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Why is patient centered care important for a pharmacist?
a. most medical treatments are for chronic conditions and pharmacists need to help their patients with therapy management. b. patients have questions about drug therapy that they don't ask. c. patients make autonomous decisions about their use of medications. d. patients often do not understand medication instructions e. all of the above. |
e. all of the above
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A health behavior theory that describes the likelihood an individual will take action to change a behavior
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Health Belief Model
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In the health belief model perceived ____ and perceived ____ make up the perceived threat. Meanwhile perceived ___ and perceived ____ make up the perceived benefits.
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susceptibility; severity; benefits; costs
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The three factors that lead to likelihood of change in the health belief model are _____ ______, perceived threat and perceived benefit.
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self-efficacy
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The purpose of patient empowerment is to encourage patients to get involved in their own ______ and be aware of alternatives. This helps the patient avoid _____ _____.
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healthcare; medical error
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Empathetic listening and understanding (verbal and nonverbal):
a) is perceived by patients as evidence of caring and concern b) contributes to a patient’s sense of worth and dignity c) encourages patients to share concerns or confusion d) facilitates patient’s own problem-solving e) all of the above |
e) all of the above
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What is the part of empathic listening that involves the patient perceiving you as honest in your communication?
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Genuineness
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One of the biggest barriers to effective communication is our tendency to _____ the other person. Patients feel are being judged will not reveal issues they have with ______.
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Judge; therapy
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The main point of Respecting patients:
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Not judging patients because they will not be complaint or open to talk about health care.
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Appropriate listening/empathic behaviors include everything BUT:
a) Looking at the patient b) 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 |
b) Crossing your arms
NOT crossing your arms is the appropriate response. |
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______ of feeling responses tend to be perceived by patients as understanding and nonjudgmental. _____ very briefly what you understand the patient is feeling based on what he/she has told you.
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Reflection; Rephrase
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T/F During an empathic response, you want to change the person's feeling from a negative one to a positive one.
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False. You do not want to change their feelings only convey understanding.
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______ questions are used to access information about current drug therapy in order for the patient to describe to you everything he/she takes.
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open-ended
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When opening a(n) ______, you always want to address the patient by name, introduce yourself formally and explain the purpose of the interview.
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Interview
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“What did your doctor tell you this medication was for?” is a good question to assess the ____ of the drugs.
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purpose
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When a patient does not take their medication it is important not to do what?
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get angry, judge them, yell.
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_____ can be evaluated by the patient and physician. Therefore lab values as well as patient input are very important in determining how well the treatment is doing.
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Effectiveness
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Asking questions about problems with their new medication and if they have felt any symptoms since they started is what part of the interview process?
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Assessing Problems
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T/F Assessing allergies is not part of the interview process.
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False. Assessing Allergies is part of the interview process and it should be recognized near the end of the interview.
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T/F When ending an interview, you want to make sure the patient has no questions and leaves the room understanding everything you both talked about.
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False, you want to make sure the patient asks questions and that you are making yourself available to answer them whenever he/she needs the answers.
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All of these are part of what process/technique?
i) Ask patient to summarize information presented ii) Ask patients to demonstrate administration iii) 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.”) iv) Allows you to verify understanding, fill in gaps, and correct misunderstandings |
“Tech Back” Technique
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Healthcare professionals should avoid health-jargon because of:
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Low health literacy
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language that everyone understands to avoid making the patient feel stupid and out of place. (Also known as...)
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living room??
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The _____ ____ model involves community and health systems working together to produce productive interactions between the informed active patient and prepared proactive practice team
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The Chronic Care Model
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When many different professionals work for the good of the patient, although somewhat independently. An example of this is how a doctor writes a prescription and the pharmacist fills it without ever having to call the doctor.
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Multidisciplinary Care
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Many different professionals work for the good of the patient, communicating effectively among themselves and with the patient. Hospital/Medical Home setting.
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Interdisciplinary Care
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List 5 professions involved in a medical home.
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Pharmacist, Physician, Nurse, Physical Therapist & Social Worker
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An approach to providing comprehensive primary care... that facilitates partnerships between individual patients, and their personal Providers, and when appropriate, the patient’s family
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Medical Home
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What are all of the following grouped under?
a) Health care reform b) No “pre-exisiting 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 |
Developments that will affect health care system
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Congress passed the _______ Act and greatly increased the number of hospital ____ 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.
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Hill-Burton; beds
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Congress created financial incentives to encourage the _____ of more and more health care professionals.
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education
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c) Congress established Medicare (_____) and Medicaid (____) to improve access for the poor and the elderly in the year ____.
Fill in top blanks with either poor or elderly. |
elderly; poor; 1965
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HMO
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Health Maintenance Organizations
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MCO
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Managed Care Organization
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A type of managed care organization that shares risk with a network of health care providers by requiring that the providers assume some risk, either directly or indirectly, and that generally does not provide coverage for medical care that is received outside the network.
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HMO aka Health Maintenance Organization
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Risk arrangement is categorized in two ways: _____ and _____
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Capitation and Risk pool
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providers are paid a fixed amount each month for each enrolled patient, regardless of the amount of health care service actually provided.
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Capitation
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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.
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Risk pool
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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.
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Gatekeeper
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The Gatekeeper position helps to limit...
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unnecessary and often expensive referrals to specialists
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JCAHO
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Joint Commission of Accreditation of Healthcare Organizations
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A nonprofit organization that sets standards of practice for, evaluates and accredits more than 15,000 health care organizations and programs in US
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JCAHO
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This accreditation is required to in order to receive reimbursement for Medicare and Medicaid programs.
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JCAHO
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DRG
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Diagnosis-Related Group
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A categorization of diseases of conditions created initially by the federal government as a means to reimburse hospitals prospectively for services provided to patients.
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DRG - Diagnosis Related Group
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How hospitals and other care providers bill insurance companies.
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DRG
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Hospitals can be classified by the following except:
a) Ownership b) Length of Stay c) Type of Service d) Type of Health Coverage e) all of the above |
d) Type of Health Coverage
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What type of hospital serves veterans, military personnel, and native Americans populations?
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Federal government—aka public hospitals
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What type of hospitals are owned and operated by city, county or state governments?
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Nonfederal government—aka public hospitals
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Non-government hospitals fall under two categories...
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not-for-profit AND Investor owned for profit
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What type of hospital reinvests financial surplus at the end of the year into the organization (new equipment, remodeling, or new buildings)?
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not-for-profit
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What type of hospital reinvest financial surplus at end of the year into the organization plus gives some money to the investors in the form of dividends?
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Investor owned for profit
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What type of hospitals provide a variety of services including general medical and surgical services?
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General Hospitals
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What type of hospitals concentrate on one disease process or on one segment of the population?
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Specialty Hospitals
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If you pay a set dollar amount of the expenses each year before your health insurance begins to pay, then your insurance plan includes
A. A deductible B. Copayments C. A fee for service D. A co-insurance requirement |
A. A deductible
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Which of the following statements best describes prior authorization under a prescription drug plan?
A. Getting plan permission in advance before it will cover a specific prescription B. Allowing only a certain quantity of the prescription C. Asking a patient to try less expensive drugs before the plan will cover more expensive drug D. Allowing only a certain dosage of the prescription |
A. Getting plan permission in advance before it will cover a specific prescription
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In general, a risk is NOT considered insurable if the event
A. Involves minimal financial loss B. Happens accidentally C. Occurs at random among a group of individuals D. Occurs with predictable frequency |
A. Involves minimal financial loss
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The reason that there is a penalty assessed on persons who do not sign up for Medicare Part D when they are first eligible is
A. To discourage induced demand B. To ensure coordination of benefits among multiple insurance plans C. To avoid problems with adverse selection D. To maximize the total value of premiums paid into the Medicare Trust Fund |
C. To avoid problems with adverse selection
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The reimbursement mechanism generally used under a traditional insurance plan is
A. Prospective payment B. Fee-for-service C. Cash paid at the time service is given D. Capitation |
B. Fee-for-service
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What is the classification of a hospital with patients that have an average stay of fewer than 30 days?
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Acute Care Hospitals
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What is the classification of a hospital with patients that have an average stay of more than 30 days?
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Long-term hospitals
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______ is funded by the federal government and therefore the requirements and benefits are the same through out the country. It is funded by ___ ___ ___. Part D plan (PDP) began in 2006. For disabled and persons over age ___.
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Medicare; Federal Trust Funds; 65
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PDP
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[Medicare] Part D Plan
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Medicare Part A includes...
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Hospitalizations
1. Deductibles and Co-payments 2. Acute Care 3. Skilled Nursing Facility |
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Medicare Part B includes...
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Physician services
1. covers outpatient care (e.g., chemotherapy), preventive services (e.g., vaccinations), Durable Medical Equipment (DME) 2. 20% co-payment for covered services; otherwise 100% 3. Physician needs to accept medicare payment 4. Balanced billing allowed up to 115% approved charge |
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Medicare Part C includes...
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Managed Care Options (MCO) including:
* Medicare managed care plans; * Medicare preferred provider organization (PPO) plans; * Medicare private fee-for-service plans; * Medicare specialty plans. |
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PPO
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preferred provider organization
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_____ is administered by each state and receives financial support form the federal and state governments for persons of low income.
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Medicaid
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The portion of medicaid funded federally is _#_ but it varies by ____. This is based on average ____ relative to national average,
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>50%; state; income
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Historically in Florida medicaid is ___-___% federal funds. “____ ____” in Florida 2009 & 2010 to 66.7%
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55-60; Enhanced Match
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DHHS
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US Department of Health and Human Service
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What organization is responsible for administration and eligibility for Medicaid & Medicare?
In Florida eligibility is determined by the ______ and the program planning and operations is done by the _____ division of Medicaid services. |
US Department of Health and Human Service (DHHS) Centers for Medicare and Medicaid Services
Department of Child & Families; AHCA (Agency for Healthcare Administration) |
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AHCA
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Agency for Healthcare Administration
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ALS
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Lou Gehrig’s Disease
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ESRD
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End-stage renal disease
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What makes you eligible for Medicare?
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1. Over the age of 65
2. End Stage Renal Disease (ESRD) 3. ALS (Lou Gehrig's Disease) 4. Permanent disability patients from Social Security |
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All of the following make you eligible for Medicare except:
a. Over the age of 65 b. End Stage Renal Disease (ESRD) c. Families below asset threshold per individual state. d. ALS (Lou Gehrig's Disease) e. Permanent disability patients from Social Security |
c. Families below asset threshold per individual state.
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Medicare Part D
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Prescription Drug Benefit
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Medicare covers about __% of care on average and most beneficiaries have additional coverage.
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45
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In medicare, ____ sponsors benefits for retirees, ___ types of plans are allowed.
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employee; 12
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Dual eligibles
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are individuals who are in receipt of medical coverage from both Medicare and Medicaid.
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Medigap
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private plan for charges not covered by Medicare
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Elegibility for Medicare
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(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 |
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Persons that don't meet mandated requirements for Medicare but share characteristics of mandated groups. Must receive same benefits as categorically needy. (determined by each state)
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Categorically needy optional
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Medically Needy for Medicare Eligibility
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(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 |
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Are nursing facilities required services of medicare? T/F
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True.
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List Four Required Services of Medicare
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(a) Inpatient hospital
(b) Outpatient hospital (c) Physician services (d) Labs & Xrays (e) Nursing facilities (f) Home health (g) Pre-natal care, family planning (h) EPSDT (i) Rural clinics, etc. |
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EPSDT
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Early Periodic Screening, Diagnosis & Treatment
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Medigap
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private plan for charges not covered by Medicare
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DME
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Durable Medical Equipment
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Acute Care consists of __ days medically-necessary per benefit period with __ days lifetime reserve.
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90; 60
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Skilled Nursing Facilities consist of ___ days per benefit period preceded by greater than ___ hospital days within last 30 days.
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100; 3
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What is NOT covered in Medicare Part B?
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dental care
hearing aids vision care routine annual physical exam |
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CHIP
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Children's Health Insurance Program
Reauthorization Act of 2009 |
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T/F Almost 1/2 of uninsured children live in households below 200% of poverty with an adult working.
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False, Almost 3/4 of uninsured children....
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____ allowed for expansion of Medicaid-type services to low-income children with no health insurance
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CHIP
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200% of poverty in Florida or $______
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$44000
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T/F An estimated 5 million children eligible for Medicaid under CHIP but not enrolled
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True
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Recovery Act funds have extended programs and funds under ____ Act.
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CHIP
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CHIP allows the state to set premiums and cost sharing on a _____ scale
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sliding
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If you don't sign up for Part D when you are first eligible...
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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).
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Annual enrollment period for Medicare
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Nov 15 - Dec. 31
(in Suzy's notes it says Dec 15... but i checked online and it said 31st... ) |
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Credible coverage
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acceptable alternative. 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.
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Rules for Part D:
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a) Formulary- Some drugs not covered
b) Financial Incentives- copays and deductibles c) Prior Authorization- meet certain criteria before prescribing d) Step Care- Oldest cheapest before newest more expensive e) Quantity limits- How much of a drug you can receive at one time. |
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FFS
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Fee for Service
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reimbursement in which a fee is paid to a provider for each service performed. Was the predominate reimbursement mechanism before managed care. Provide incentives to increase the quantity of services provided.
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Fee for Service
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Providers are paid a fixed amount each month for each enrolled patient, regardless of the amount of health care service actually provided.
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Capitation reimbursement
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PBM
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Pharmacy Benefit Management
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The following are prerequisites of Insurance Except:
a) Known peril with predictable frequency b) Peril occurs at random among individuals c) Losses are accidental d) Losses are substantial e) Losses are indeterminate |
e) Losses are indeterminate
Losses ARE determinate!! |
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T/F A prerequisite of Insurance is that the policy holder must have an insurable interest.
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True
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Problem:
Catastrophic Hazards |
Solution:
Coverage limits |
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Coverage limits
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max amount that person can receive when they receive medical attention
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max amount that person can receive when they receive medical attention
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Coverage Limits
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Adverse Selection
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only sick people join and not healthy people
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Problem:
Adverse Selection |
Solutions:
Group policies Elimination Period |
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Group policies
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businesses that offer insurance and everyone has to join that insurance plan
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Elimination Period
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waiting period after joining insurance before you can receive benefits.
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Problem:
Moral Hazard |
Solution:
Coordination of benefits |
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Moral Hazard
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gain from apparent loss
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Coordination of benefits
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only 1 insurance will pay at a time if you have multiple insurances
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Problem:
Induced demand |
Solution:
Cost-Sharing |
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Induced demand
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Used too much
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Cost sharing
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patient share the medical cost with the insurance company. Examples include copayments and co-insurance.
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Pharmacy Benefit management:
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represent the third party payer
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Pharmacy Benefit Management assumes the responsibility for...
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agreements with participating pharmacies.
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Formularies
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The drugs approved for use in a hospital or for reimbursement. Prevents expensive and unnecessary drugs from being charged to the insurance.
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patient share the medical cost with the insurance company. Examples are co-payments, deductibles, out-of-pocket, co-insurance, and max benefits
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Cost-Sharing
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IOM
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Respects patients values, preferences and expressed needs
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JCAHO leaflets: “Speak Up: Help Prevent Errors in Your Care”
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Example of patient empowerment initiative
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AHRQ: 20 tips to help prevent medical errors
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Example of patient empowerment initiative
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Institute for Safe Medication Practices
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Example of patient empowerment initiative
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Name at least 3 important communication skills for health care professionals
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- Emphatic listening and understanding
- Genuineness - Respect for the patient |
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Benefits - ECHO
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- Economic (time and Money)
- Clinical (death, disease, disability, discomfort) - Humanistic (satisfaction, quality of life) - Outcomes |
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lab tests, drugs, equipment, etc
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Direct medical costs
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travel, child care, waiting times in doctors office – not usually covered by insurance
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Direct non-medical:
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pain, suffering
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Intangible Costs
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loss of productivity or burden to family/friends
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Indirect Costs
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Comparative Effectiveness' Purpose?
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To inform patients, providers, and decision-makers, responding to their expressed needs, which interventions are most effective for which patients under which specific circumstances
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American recovery and reinvestment act of 2009
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Set aside $1.1 billion for comparative effectiveness research from tax on health insurance premiums and public programs
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Results of American Recovery & Reinvestment Act are NOT to be used to...
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• Mandate coverage
• Establish reimbursement • Set policies for public or private payers |
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Federal Coordinating Council for Comparative Effectiveness
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Priority populations → priority conditions → types of interventions
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Explain the typical prescription pricing scheme involving a dispensing fee and ingredient cost as components.
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Cost of product + dispensing fee = pharmacy retail price
pharmacy retail price – beneficiary cost share = amount paid by third party |
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Third party payers recognize that pharmacy’s ___ is less than ___
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AAC; AWP
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AAC
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Actual Acquisition Cost.
Actual selling price from wholesalers to pharmacies |
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AWP
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Average wholesale price.
Wholesalers distribute pharmaceuticals to pharmacies with AWP as the list price. |
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U&C
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Usual and Customary.
Cash customers pay the pharmacy’s U&C |
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AMP
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Average Manufacturers Price
– actual selling price. Manufacturers sell primarily thru wholesalers but will sell large volumes directly to hospitals, chain pharmacies, etc. |
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WAC
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Wholesale Acquisition Cost.
Manufacturers establish as the price sold to wholesalers |
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EAC
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Estimated Acquisition Cost –
calculated (WAC + %) or (AWP - %) |
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MAC
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Maximum Allowable Cost
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FUL
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Federal Upper Limit
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Third parties reimburse pharmacies a dispensing fee plus ingredient cost. What are the equations for generic & brand?
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Generic: MAC/FUL
Brand: EAC |
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Tiered co-payments
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PBMs use tiered co-payments to drive drug utilization away from high cost, brand name medications to lower-cost alternatives. In three-tiered pharmacy benefits, generic drugs are placed in the first tier of the formulary and have the lowest co-payment, preferred brand name drugs are placed on the second tier with a higher co-payment, nonpreferred brand-name drugs are placed on the third tier and have the highest co-payment, some plans specific fourth tier co-payments with certain “lifestyle” drugs (ex: Viagra) or nonformulary drugs.
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Quantity limits
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PBMs may limit the size of a particular prescription or the number of refills. Size may be limited to a specified number of dosage units or a specified day’s supply (usually 30 days). Early refills may not be allowed unless the PBM gives authorization to do so
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Prior authorization
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allows a patient’s physician to request coverage of nonpreferred or noncovered medications
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Step therapy
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the use of more expensive agent is reserved for second-line treatment if treatment with the less expensive agent proves unsuccessful. Ex: patient required to try aspirin/generic NSAID before coverage of a brand name NSAID or COX-2 inhibitor will be authorized
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Which of the following is NOT a PBM's role?
a. Communication with providers and beneficiaries b. Reimbursing providers c. Agreements with participating pharmacies d. Mail order options e. None of the above. |
e. None of the Above.
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T/F A PBM's role includes utilization review/auditing providers and controlling costs.
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True
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T/F PBMs do not assume responsibility for benefit design.
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False.
PBMs DO assume responsibility for benefit design (which drugs should be covered) |
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T/F PBMs do not negotiate on behalf of private insurers.
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False.
They do negotiate on behalf of private insurers |
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Prescription drugs are relatively ____ percentage of health care expenditures overall
Drug costs are rising faster than other sectors &drugs account for most out-of-pocket expenses. |
small
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Expenditures for prescription drugs rising because:
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o Utilization (using more drugs than in the past)
o Prices o Changes in types of drug uses |
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Deductible
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pay certain amount of expenses before insurance pays thereby minimizing risk to insurer.
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Co-payment
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fixed amount per service. Minimizes risk to insurer.
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Co-insurance
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pay percentage of cost. Minimizes risk to insurer
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Coverage limits
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after you spend a certain amount, no more is covered which minimizes risk to insurer.
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Causes a 99.9% reduction in transactions, high availability.
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Pharmaceutical Wholesaler
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3 Primary national wholesalers: __% of prescription sales: ___, ___ & ___.
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90%; McKesson; Cardinal Health; Amerisource-Bergen
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___ # of Regional Wholesalers
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33
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Traditional, Clinic, Franchise. Makes up 17% of retail sales.
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Independent Community Pharmacies
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Drug Store Chains, Supermarkets, Mass Merchandisers. Make up 67% of retail sales.
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Chain Community Pharmacies
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Cost Breakdown of Prescriptions:
79.6% --> _____ 17.3% --> ______ 3% --> _____ |
Drug Manufacturer; Retail Pharmacy; Wholesaler
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Equation for Total Prescription Cost
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Cost of Product + Dispensing Fee = Total Prescription Cost
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Price Makers:
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Manufacturers, Wholesalers, and Insurance Firms constrained by competitors
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Price Takers
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Dispensing Pharmacies
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• Revenue increases ad number of products increase
• Revenue generator is the pharmacy department |
Fee For Service System
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• Fixed revenue so costs increase as products increase
• Cost center is pharmacy department |
Fixed Payment System
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