Basics of managed care Flashcards
Discuss recent trends in health care plans
Anthem - starts its own PBM
CVS - care mark PBM - acquired aetna
Cigna- acquired express scripts PBM
United health acquired catamaran optum PBM
Describe the goals and rationale for managed care plans
Managed care is an approach to the delivery of healthcare services in a way that puts limited resources to best use in optimizing patient care
Goals: prevention of disease, focus on wellness and enhanced QOL, improved clinical outcomes, quality and accessibility of health care, cost containment
Describe how managed care principles are woven into employer provided plans, private plans, Medicare, and Medicaid
Describe the basic components of an employee’s healthcare plan
Center for health living office visits, primary care office visit, specialty care office visit, preventive care, emergency room, urgent care facility
Discuss major events in the evolution of manage care in the US
Discuss the major tools used in the pharmacy benefit component of a managed care plan
Define common terms and abbreviations used in managed care
Deductible - out of pocket payment before health care benefits become payable
Prior Authorization - An administrative tool used by health plans or prescription benefit management companies (PBMs) that requires prescribers to receive pre-approval for certain drugs to qualify those drugs for coverage under the terms of the pharmacy benefit.
Describe potential roles for pharmacists in managed care
Drug information, medication therapy, product development, client relations, industry relations, health economics, government programs, specialty pharmacy
