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Health-Care Systems > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

What is a PBM

A

Pharmacy benefit manager
Private companies that specialize in Rx drug claims and coverage
administrative services only
assume no financial risk

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2
Q

what do PBMs do

A

contract and build networks of retail pharmacies from which patients can purchase their prescriptions
formulary development and management
Utilization and cost management
Claims processing and provider payment

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3
Q

what is the equation of prescription payment from PBM

A

Rx Payment from TTP (third party payer, in this case PBM)=
product cost + dispensing fee - patient share cost

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4
Q

what is used to calculate the product cost for single source, brand name drugs

A

Estimated acquisition cost (EAC)=
AWP- (AWP(x%))

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5
Q

what is used to calculate the product cost for multisource, generic drugs

A

Maximum allowable cost (MAC)

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6
Q

If a drug has a brand name and generic name drug available, and the Rx is written for the brand name drug, what variable do you use to calculate the product cost

A

EAC because you must dispense the rx as written for the brand even though generic is the cheaper default option

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7
Q

Define WAC

A

Wholesale acquisition cost
manufacturer’s published list price for sale of a drug (brand or generic) to wholesalers
WAC is approx for what pharmacies pay wholesalers for BRAND-NAME drugs
exceeds pharmacies’ acquisition costs for generics

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8
Q

AMP

A

Average manufacturers’ price
average price actually paid to manufacturers by wholesalers for drugs in retail pharmacies or for drugs bought directly from manufacturers
Used by gov’t as estimate for Medicaid generic Rx

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9
Q

AWP

A

average wholesale price
suggest list price for products purchases from wholesalers sold to pharmacies
pricing index to determine the pharmacy payments from PBMs

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10
Q

AAC

A

Actual acquisition cost
actual amount paid by a pharmacy to supplier for a product
typically unknown so rarely used for determining reimbursement amounts under Rx benefit plans

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11
Q

EAC

A

estimated acquisition cost
estimate of AAC use to determine reimbursement amount for single source drugs
EAC = AWP- AWP (%)

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12
Q

MAC

A

maximum allowable cost
max amount per unit of meds that PBMs will pay pharmacies for multisource drugs, regardless of amount pharmacy actually paid
creates incentive to spend less on generics

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13
Q

what are the 8 mechanisms PBMs use to control drug costs and increase their revenue

A

spread pricing
rebate with drug manufacturer
formularies
prior authorizations
quantity limits
step therapy
generic drug use
mail service options

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14
Q

define spread pricing

A

bill health plans more for Rx claims than pharmacy is reimbursed for its product costs and dispensing services

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15
Q

define rebate
what are the two forms of it

A

To the PBMs from manufacturers for single source brand name drugs to encourage PBMs to increase the market share for a specific med
Two forms: flat rate rebate and market share

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16
Q

define flat rate rebate

A

rebate based on a fix percent of the WAC

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17
Q

define market share rebate

A

rebate amount based on market share each PBM achieves for specific product
increased by the PBMs promotion of drug
lower co-pays
market share = # Rx for specific drug / # Rx for entire drug class
both covered by PBM

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18
Q

Formulary

A

list of medication covered by third party payer
includes tiered copays
lowest copay for generics
brands
nonpreferred brands
highest copay for specialty drugs

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19
Q

Prior authorizations

A

providers must get approval from insurance showing the patient meets specified criteria before the patient can receive the drug
criteria includes contradictions/allergies to preferred medications, failed prior treatment with preferred medication
delay in patient access or prescribing less effecting med to avoid hassle can result
very time intensive for provider and pharmacy staff

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20
Q

quantity limits

A

limits on # days supply or number of dosage units of medication allowed per Rx or time period

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21
Q

step therapy

A

prescribing pattern/protocol using the most cost-effective drug first

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22
Q

generic substitution

A

use of the generic drug if available, some cases only the generic will be covered

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23
Q

mail service options

A

option offered by prescription benefit plans where enrollees can pay lower cost-sharing amount and are able to obtain greater quantities

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24
Q

How are retail pharmacies reimbursed for prescription drugs under Medicare? Single source and multisource?

A

through stand-alone Part D (PDP) or medicare advantage prescription drug plans (MA-PD)
both are administered by private insurance companies that reimburse retail pharmacies for Rx drugs through PBMs using the same standard formula
Single source use EAC
Multisource use MAC subject to FUL

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25
Q

Describe FUL

A

Federal Upper Limit
States that receive federal funding for Medicaid can’t pay more than the federal upper limit for multi-source generic drugs
published by Center for Medicare and Medicaid Services (CMS)
Calculated using AMP

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26
Q

What are the roles of drug wholesalers

A

prime vendors; intermediates in the drug supply line like the PBM in the reimbursement line

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27
Q

why do pharmacies use drug wholesalers

A

reduce number of invoices
reduce inventory with multiple deliveries per day
Improved cash flow

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28
Q

Group purchasing organizations

A

group of health organizations in community or hospital setting that are brought together to provide large numbers that can leverage purchases and negotiate drug prices

29
Q

Pros of open channel drug distribution

A

maximize access to drugs for patients with relatively common diseases

30
Q

Cons of open channel drug distribution

A

manufacturers have little control over inventory
delay in delivery on information about prescribing patterns or patient outcomes

31
Q

Pharmacy Benefits

A

bill and dispense
NDC: specific drug name, manufacturer, form, strength, container
copayment or coinsurance for drug
cost controls (better coverage for generics, quantity limits, prior authorizations, step therapy

32
Q

Medical Benefits

A

Buy and bill: Purchase administer, bill
HCPCS Code (specific drug/drug class but not manufacturer, strength, package size)
copayment for office visit, no cost-share for drug
no price differentiation between generic and brand, weak control

33
Q

Specialty Drugs

A

Expensive and require more clinical attention

high cost
treat rare conditions
injectables (usually)
produced via biotech (usually)
requires therapy management by HC professional (high incidence of adverse effects and compliance problems
FDA required REMS

34
Q

2 drivers of specialty drug trend

A

high cost per patient
increased utilization (more drugs off drug pipeline, earlier use of biologics in regimens, new indications)

35
Q

Limited drug distribution

A

Small number of distributors: drug only in few specialty pharmacies or wholesalers
patients with relatively rare conditions
Specific drug shipped for specific patient

36
Q

REMS

A

risk evaluation and mitigation strategy
for drugs with potential serious adverse side effects
developed by manufacturer and approved by FDA
Requires data on distribution, prescribed, dispensed, and taken

37
Q

How does specialty pharmacy benefit manufacturers

A

consistent data for REMS from pharmacy
better control inventory, reduced distribution costs, predicting market needs
increased access to patients through co-payment assistance and patient education

38
Q

Patient benefit of specialty pharmacy

A

quick access to drug
24 hr access to pharmacist for questions
finding patient assistant programs to overcome financial barrier
member education drug use
refill and monitoring calls
clinical programs (disease management)

39
Q

Insurer benefit of specialty pharmacy

A

shifting to white bagging which allows them to enact more cost controls
receive data from specialty pharmacy about how expensive drugs are utilized (prescribing patterns, patient adherence, effect of cost-control mechanisms)

40
Q

what are both types of pharmacy practice trying to achieve

A

improve patient’s health outcomes

41
Q

clinical pharmacy

A

product based care
focused on application of knowledge
patient counseling
therapeutic drug monitoring
by pharmacist

42
Q

pharmaceutical care

A

introduced in the 1990s
patient centered
outcome oriented
requires inter-professional cooperation
disease management
medication therapy management

43
Q

3 reasons for the shift to patient centered care

A

patient compliance: understanding health background and cultural context improves adherence
prevalent chronic conditions: increase value on quality of life
managed care cost-containment strategy: cheaper to prevent diseases than treat serious illness

44
Q

Under OBRA ’90, pharmacists are expected to offer an explanation of the prescription drug regarding…?

A

purpose
proper administration
common adverse effects
potential interactions
contraindications to use of drug
guidance on steps to take given specific outcomes

45
Q

General information about patient counseling including the way pharmacists are paid for the service.

A

no proper payment structure or compensation
following directions and optimizing health is ultimately up to patient
need yes or no if counseling was offered
no follow up required

46
Q

disease management

A

coordinated health interventions for the define patient populations with chronic conditions
interprofessional
need significant self care
addresses patient’s drug and nondrug therapy, lifestyle modifications
no adequate compensation; service reimbursement under physician in inter-professional team

47
Q

what law created MTM

A

Medicare Prescription Drug Improvement and Modernization Act of 2003

48
Q

Goal of MTM

A

optimize therapeutic outcomes through improved medication use, and to reduce the risk of adverse events including adverse drug interactions

49
Q

CMS guidelines

A

Guidelines: NOT services of patient counseling or disease management, they didn’t further elaborate, very unclear
Eligibility

50
Q

eligibility of MTM

A

multiple chronic disease states
taking multiple medications
spend more than a specified amount on Rx meds

51
Q

five core elements of MTM

A

comprehensive medication review (CMR): pharmacist asses all current medications
personal medication record (PMR): record for the patient of all of their medications
medication related action plan (MAP): document for the patient to use in tracking progress for self-management
intervention/referral: medication related problems if present
documentation and follow-up: evaluate patient progress and billing purposes

52
Q

Patient counseling vs. MTM

A

patient counseling: required, no documentation required, rx specific, not wholistic, no formal payment

MTM: only required for Medicare Rx drug plans, requires documentation (for follow up and billing), wholistic, has follow up, can bill for service

53
Q

what does gaining the “provider status” means for pharmacists

A

able to make claims directly to third-party payer for services they provide and the value of those services is properly recognized

54
Q

Rational for pharmacists to obtain provider status

A

Need primary care service providers
in medically underserved areas
many patients with chronic diseases managed by chronic medications
movement toward pay-for performance through coordinated care, team-based approach

55
Q

What are the 3 efforts on the Federal pathway to attaining provider status

A

Amending Social Security Act to list pharmacists as a provider
Pharmacy and Medically Underserved Areas Enhancement Act: all ow pharmacists to deliver care to patients in federally defined medically underserved communities
Equitable Community Access to Pharmacists Services Acts: establish Federal reimbursement mechanism for pharmacists services under Medicare Part B; allow for testing, treatment, and vaccinations

56
Q

What are the 3 areas pharmacists try to improve at the state level for provider status

A

provider designation
scope of practice
recognition by payers

57
Q

Rule 89

A

Pharmacists
procurement of drug products insuring their strength, quality, purity, and labeling from licensed and lawful distributors
accurate interpretation and dispensing associated with legal and legitimate prescriptions
Shall not fill an Rx where
improperly written
susceptible to more than one interpretation
where there is reason to believe it will harm the patient
where there is reason to believe it will be used for other than legitimate medical purposes
communicate to patient or patient caregiver (patient counseling)

58
Q

Describe the different roles and responsibilities of pharmacist and technician.

A

pharmacist can delegate some of their tasks to licensed or unlicensed person if the pharmacist
determines knowledge and skills necessary
determine delegate posses knowledge and skills
provides policies and procedures for these functions
supervise and evaluates the delegate
provides remediation
and pharmacist bear the ultimate responsibility for performance of delegated tasks and functions

59
Q

Licensed nurse on duty 24 hrs a day and higher level of care

A

skilled care/hospital like

60
Q

more regulations and mandated monthly pharmacist chart review

A

hospital like/skilled care

61
Q

costs about $6400 but is typically paid for by managed care

A

hospital liked/skilled care

62
Q

staffed by medical assistants and has higher functioning patients

A

home-like/assisted living

63
Q

no mandated pharmacist chart review

A

home-like/assisted living

64
Q

licensed nurse on-call or present

A

home-like/assisted living

65
Q

average cost $3500 and paid for out of pocket

A

home-like/assisted living

66
Q

Part A coverage of activities of daily living

A

skilled care after hospital stay
day 1-20: $0 copay
day 21-100: $161/day copay
day 101+: no part A coverage

67
Q

Part B and D coverage of activities of daily living

A

After 100 days:
Part B or D does not cover activities of daily living
Part B only covers physician services and durable medical equipment
Part D pay for Rx

68
Q

What will Medicaid cover

A

Activities of daily living (ADLs)
medications
other necessary services and equipment
NOT ALL facilities accept Medicaid
Patients must meet asset/income requirements

69
Q

Who is subject to strict annual inspections by the state

A

skilled care nursing facilities

Health-Care Systems (3 decks)

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