Final Flashcards
What is the 3 tier system of medication distribution
manufacturers
wholesalers
retail pharmacies
What are the 4 sections of medication distribution
manufacturers
research and developement services
management of med use
pharmacy wholesalers
retail pharmacies dispense to pt
What are biopharmaceutical industry companies goal
develop, manufacture, market, distribute drugs
What does the FDA oversee
drug safety and efficacy
marketing and promotion
product communications and labeling
What are me-too drugs
drug entering into a drug class which brings no new health benefit to market
What are PhRMA issues
research/product selection
direct to consumer advertising
pay to prescribe
What do PBMs manage in outpatient medication for beneficiaries
establish formulary for insurance plan
(purchase drugs, negotiate prices)
manage use of med by pt (star rating)
charge DIR fees to retail pharmacies
What are wholesalers
purchase, inventory and sell a manufacturers complete pharmaceutical product line
What are the 4 wholesaler trends
improve generic marketplace
evolution/growth of specialty pharmacy
grow rx demand and customer consolidation
era of global drug distribution
How are wholesalers benefitting to clinents (pharmacies)
price advising
educational resources
marketing resources
software resources
manufacturer relationships
What is buying power (group purchasing organizations)
small/regional chains and independents align with other pharmacies to form purchasing groups
incentive to work together to increase business
Pharmacy service functions can be completed by an outside vendor or entirely carved out because of what 3 things
Pharmacy is an easily defined benefit
Pharmacy has a defined pt pop
High or rising costs
Key pbm activities
Manages reimbursement
Consultation for benefit design
Creates retail markets
Rebate programs
Specialty mail
P&T committees
Capabilities reporting
What are the parties involved before a prescription drug is reimbursed and finally reaches the patient
Drug -> manufacturers -> wholesaler
Rx -> prescriber -> payer
Both go to pharmacy and then pt
AWP (average wholesale price)
Most common used in drug pricing
Third parties publish this price for public knowledge
WAC (wholesale acquisition cost)
Most common for pharmacy purchasing of drugs
Published by manufacturer for sale via wholesaler
Pricing does not exist for all drugs
GPO (group purchasing organizations)
Group purchasing organization created to leverage the purchasing power of a group of businesses to obtain discounts from vendors based on the collective buying power of the GPO members
NADAC (national average drug acquisition cost)
Average wholesale price calculated by what is paid by retail pharmacies for prescription and OTC
Data generated by monthly surveys and updated weekly
Utilized by CMS
AMP (average manufacturer price)
Part of OBRA
Average price paid to the manufacturer for the drug in the US by wholesalers for drugs distributed to the retail pharmacy class of trade excluding customary prompt pay discounts extended to wholesalers
Best price
Brand name drugs
Lowest price available from the manufacturer during the rebate period to any entity in the US in any pricing structure
AWP roll back
Brand drugs AWP has correlation to WAC
The listed AWP for most brand drugs was “rolled back” 5%
FDB no longer publishes the AWP price
PSAO (pharmacy services admin organizations)
Basically reimbursement GPO
Help negotiate the highest reimbursement for the individual pharmacies
MAC (maximum allowable cost)
Applies to multi source generic drugs
Payer or PBM determined price
Price allows payers to pay the same price for a drug
Cost savings tools
Formulary
Generic substitution
Drug utilization review
Quantity limits
Prior auth option
Step therapy
Admin fees
Fee charges for every claim processed
Spread pricing
What PBM charges plan sponsor is different than what pharmacy is reimbursed
MAC list
Proprietary list of meds and max reimbursement price that PBM uses
Rebates
Portion or all can be passed to plan sponsor or PBM can keep percentage
Drug pricing is variable based on the type of what transactions
Wholesaler to pharmacy
Pharmacy to third party payer
Pharmacy to Medicaid
Who dictates value based care
NCQA, CMS, AHRQ, IHI
What is NCQA
develops performance measures known as the healthcare effectiveness data and information set (HEDIS)
What are the 3 programs under CMS
medicare shared savings programs (MSSP)
bundled payments for care improvement (BPCI)
quality payment program (QPP) - includes MIPS/APM
What is ARHQ
producing evidence to support the development of quality metrics that improve healthcare delivery
What is IHI
develops and promotes quality improvement strategies and collaborates with other orgs to create quality metrics
IHI quintuple aim
pt experience
pop health
reducing cost
care team well-being
health equity
Improving population health goal
enhance the health of populations by focusing on preventive care, chronic disease management, and addressing social determinants of health
Improving population health key focus
reduce health disparities, improving access to care, implementing community based interventions
Improving the patient experience of care goal
improve the quality of care from the patient’s perspective, making healthcare more patient-centered
Improving the patient experience of care key focus
enhance communication, pt satisfaction, and engagement. It emphasizes ensuring that care is respectful of and responsive to individual patient preferences, needs, and values
Reducing per capita healthcare costs goal
control the rising cost of healthcare by improving efficiency and reducing unnecessary spending, all while maintaining or improving the quality of care
Reducing per capita healthcare costs key focus
optimizing resource use, reducing waste, and managing healthcare costs across the system (encourage value-based care models that reward outcomes rather than volume)
Improving the work life and well being of healthcare providers goal
to prevent burnout, increase job satisfaction, and enhance the overall quality of care provided
Improving the work life and well being of healthcare providers key focus
adress burnout, promote work-life balance, create supportive network environments
Achieving high equity goal
ensure that all individuals have access to high-quality healthcare
Achieving high equity key focus
Reduce healthcare disparities, improve access to care for underserved and vulnerable populations
PCMH (patient centered medical homes)
improve primary care delivery by making it more patient-centered, accessible, and coordinated
emphasizes continuity
strong focus on preventative care and coordinated care across providers
PCMH key features
pt centered care
comprehensive care
coordinated care
access to care
quality and safety
team-based care
ACO (accountable care organizations)
groups of healthcare providers who work together for pt
goal to get the right care at the right time while avoiding unnecessary duplication of services
ACO key features
coordinated care
shared saving model
pt centered approach
quality metrics
risk sharing
pop health management
What are the types of ACOs
medicare shared savings programs (MSSP)
commercial ACO
Bundled payments
provide a single payment for all services related to treatment or condition
encourages providers to collaborate and manage cost effectively to avoid unnecessary tests or procedures
Bundled payments key features
improved care coordination
cost savings
better outcomes
incentive for quality over volume
Value-based payment model
providers are rewarded for achieving specific health outcomes rather than volume of services provided
-hospital readmissions, improved management of chronic conditions
Capitation
providers are paid a set amount per patient per period, regardless of how much care the pt requires
Value based insurance
impact ratings compared to other pharmacies/provider clinics
increase reimbursement/get incentives for higher performance
higher performing clinics and pharmacies may get preferred status or preferenced with patients
What is Medicare star ratings
part D prescription drug plans
rating go from 1 to 5 (highest)
rating help pt compare plans and pharmacy services based on specific quality indicators
EQUIPP
performance information management tool that provides standardized benchmarked performance info needed to shape strategies and guide med-related performance efforts
DIR fees
direct and indirect remuneration fees
charged to pharmacies by PBMs/health insurance companies
these fees reduce the amount of money pharmacies actually receive
started as only part D, but may also be commercial
Tracking DIR fees
there is no current way to track them
What is tiering
a pharmacy benefit design that financially rewards patient for using generic and preferred drugs
(pay more for brands)
What structure is not applicable to plans where there is zero cost share to members for medications
tier (ex: many medicaid plans)
What is tier 0-4
0: ACA preventive medications
1: generic
2: preferred brand
3: non-preferred brand
4: specialty drugs
ACA preventive medications
required by regulation to be covered at zero cost to members for most plan types
-applied to all private plans
-made by USPSTF, ACIP, HRSA, IOM
Specialty medications
for meds such as multiple sclerosis, hemophilia, hepatitis, and rheumatoid arthritis
-infused/injected meds
-unique storage
-additional educations (REMS)
-usually not at retail pharmacies
-high cost
Member cost share
the amount of the prescription the member pays
Coinsurance
member pays a % of the total ingredient cost
Copay
member pays a flat fee for each prescription
-fee dependent on med tier
Deductible based benefits
designed as part of HDHP
deductible is applicable to medical and pharmacy spend
Mandatory mail
members can receive an initial dose at a retail pharmacy, but member will be penalized if they do not switch to mail after the first few fills
Preferred pharmacy networks
PBMs will contract specific pharmacies to be “preferred” in their network, allowing lower copays or a separate copay structure if the member uses a particular pharmacies
Specialty Benefits
all specialty drugs must go through a specific specialty pharmacy providers
-have significantly higher member cost share
Excluded drug classes
OTC, fertility drugs, erectile dysfunction drugs, growth hormone, wt loss drugs, compounds
Formulary
a formulary is a list of drugs that are covered by insurance and details of how those drugs are covered
Types of formularies
open: all drugs covered but some may have restrictions
closed: smaller list of drugs, new drugs are not added until reviewed and approved by P&T
What 3 decisions on all the following are proposed and presented to the P&T committee
formulary vs non-formulary meds
tier placements of meds
utilization management tools
Utilization management tools (aka:cost containment strategies (CCS))
implemented to promote:
prior auth, step therapy, quantity limits
Prior Authorizations
requires review and approval prior to being covered
can incorporate trials of other drugs
specific criteria approved P&T and used by reviewers
denials require pharmacist of physician reviews
Step therapy
can be set up with a PBM to have a computer system look for required drugs to use prior to coverage of requested agents
Quantity Limits
allows a limit to be placed on meds to ensure proper usage of dosage forms and can implement management of max daily dosages
Factors influencing formulary status
decision to add a drug to formulary based on efficacy, safety, cost
drug class/disease state review
novel agent or me too drug
drug orally admin or inj
What to look at if decision is made to add the drug to the formulary
what tier should drug be placed on
is it placed in “preferred” position
need to add any utilization managements
will rebates be impacted by UM
Implementation of formulary status
communications (providers/members)
PBM coding changes
posting formulary lists/pdls
posting what is required to submit for PA
Tips for point of sale
read rejection reasons
suggestions to member on next steps
initiate PA process or provider outreach
discount programs
Paramount lines of business (LOB)
commercial/exchange
medicaid terminated w/ ohio dept of medicaid in 2022
medicare
What do PBMs do for plan sponsors/health plans/payers
pharmacy network contracting (retail, mail, LTC, HI, specialty)
formulary management
administer the pharmacy benefit and plan design
pharma rebate contracting
Formulary and benefit admin
MA-PD plans and employer PDP
utilization management (UM) programs PA, ST, QL)
drug utilization review (DUR)
Clinical programs for paramount PBM
coverage determinations
medicare star rating
MTM
gaps in care
Subcontracting for paramount PBM
retail network
manufacturer rebates
Operational support for paramount PBM
prescription drug events
medicare plan finder pricing files
EOBs
part D
program audit
medicare compliance
Major sections of a PBM contract
parties to the agreement
term (3 yrs)
scope of service
compliance w/ rules, regulations, law
financial exhibit
reporting
performance guarantees
audit terms
Traditional or “lock in” or “spread” pricing
PBM pays pharmacy for a submitted brand or generic drug claim and that is different, often lower than the price pad by the plan sponsor to the PBM
Pass-through pricing
what PBM pays the pharmacy is passed through as the price paid by the plan sponsor to the PBM
said to be “transparent pricing”
How to shop for a PBM
consultant
RFP
pick winning bid
Whats in a RFP
intro and client overview
delegation of scope of services
terms and definitions
RFP questions
pricing conditions
performance guarantees
Use RFP to assess fit qualitatively
medicare part D operations
compliance w/ state and federal regulations
claims processing platform
reporting platform
customer service application
audit provisions
account term support
Tier model for part D components and definitions
range from 1-tier and 5-tier plans
the higher the tier, the more enrollees pay
UM tools for part D components and definitions
fromulary verus non-formulary (NF)
PA, ST, and QLs
Benefits for part D components and definitions
copays and/or coinsurance by tier and day supply
phase - deductible, initial coverage limit (ICL), gap, and catastrophic
What is a rebate
retrospective discount off the cost of brand drugs
paid by pharma manufacturer for preferential placement of a brand drug
rebate guarantees usually based on rebates amount per brand drug claim metric
What can a DUR, DUE, MUE be used for
medication, therapeutic class, disease state or condition, med use processes
____ focusses more on pt outcomes and quality of life
MUE
___________ typically is more criteria-based assessment of appropriate med use processes and prescribing
DUE/DUR
Goals of DUR and DUE
improve med use processes across the managed care system
encourage the practice of evidenced-based, clinically appropriate, cost-effective drug use
identify trends in prescribing
reduce drug misuse and abuse
prevent adverse drug reactions
Pharmacists Role in DUR and DUE
identifies opportunities for quality improvement
participates in effort to improve: pt outcome, quality of programs
promotes appropriate drug use to reduce overall health
carries out ethical and professional responsibility
Model of DUR program
access to member drug utilization data
qualified pharmacists with authority to review
knowledge of pop served and delivery system
availability of established standards for comparison
measurement of utilization review outcomes
Prospective DUR
screening method by which a health care provider reviews the necessity of drug therapy before it is dispensed or administered
DUR process
determine topic
collect data
data analysis
perform intervention or provide feedback
re-evaluate the program
Who benefits from DUR/DUE
plan member
health care provider
pharmacist
health care system
Who do PBMs serve
corporate health plans
health plans
self-funded employers
govt entities
third party admin
discount card/cash programs
medicare part D individuals
marketplace individuals
PBM pharmacist opportunities can be viewed in what 3 categories
clinical, operations, admin/corporate
Operations pharmacist opportunities
call center pharmacists and management
mail service pharmacy
speciality pharmacy
PA case reviews/appeals
MTM
Corporate pharmacist opportunities
account management
clinical program development
rebate management
network management
Corporate/Admin pharmacist opportunities
account management
informatics
product development
regulatory/compliance
trade relations/rebate management
data analytics/plan performance reporting
Speciality Pharmacy Providers (SPP)
provide clinical and distribution services to patients in the management of chronic, rare, or complex conditions
