Final Exam Flashcards
How do employer based population health management meet the population at work?
- health and safety fairs
- annual wellness screenings
- mass immunization events
- lunch time education sessions
- health improvement program
- union leader interactions
- prescription drug abuse program
- vendor collaboration
- teaching ZUMBA
How has the Cummins onsite pharmacist impacted drug adherence rates for diabetes, hypertension, and dysplipidemia?
has increased drug adherence
What percent of adult diabetes in the US had an A1C ≥ 8% in 2020?
27.8%
______ patients with A1c >8% with a reduction in A1c of ____% equates to savings of $281,000-963,090.
87 patients, 2.7%
Following provider outreach in southeastern indiana, metformin costs were ______
reduced
$422,1727 client savings in one year from moving _____ metformin prescriptions to _____ expensive formulations
high-cost, less
Team-based primary care improves ________.
all patient outcomes
Annual eye exam improved in just _____ weeks.
2
Cummins provided _____ and _____ support with education.
clinical, financial
Cummins extended preventative coverage for smoking cessation medications from a _____ day supply once in a patient’s lifetime to coverage for _______ of therapy every ______ days
6 months, 365
Exceptions for coverage are granted to patients on what?
insulin pumps that only work with specific glucometers/CGMs
Grandfathering of patients on what brand name medication are an exception to the exclusion of coverage change?
brand name Synthroid
Why was medication added to benefit coverage at Cummins?
administration difficulty with preferred product
How has Cummins expanded the role of pharmacists in non-traditional settings?
deprescribing medications in the context of lifestyle medication via supplements and non-pharm interventions
Population Health Services Organizations
- This centralized entity allows health care organizations to purchase shared services under value-based payment arrangements
- supports population risk managment
- via health plans
Population Health and Managed Care
money goes into analytics to make quality decisions
- star rating measures
- hedis measure
- national guidelines
- standards of care
- other evidence based interventions
Impact of the pandemic on managed care
- fast, flexible and functional
- have to get the team equipped, then do their jobs
- zoom, teams, skype, ringcentral
- telehealth
Post pandemic, Mclaren saw a _______ in medicaid enrollees in Indiana and a ________ in medicaid enrollees in michigan
decrease, increase
How did the pandemic have adverse effects on patient and consumer outcomes?
- different populations were affected differently
- SDOH
- gender
- race
- ethnicity
- zip code
Organizations who win have:
- the right mission
- the right goals
- the right tools
- the right people
- the ability to stay the course but change accordingingly
Takeaways of managed care
- define the problem
- assemble the stakeholders and the experts
- lean on the entire organization
- keep the success and celebrate them
- root out the bad
- reinforce mechanisms that work
opportunity for managed care
- use pricing information in NADAC to everyone’s benefit
- supply chain
- drug pricing
ASP
- average sales price
- ASP + 6% is how a medical provider is paid for a medicare patient in a hospital
- reward the provider for use of the biosimilar
Clopidogrel vs Tigagrelor
$4 copay plavix vs $50 copay brillinta
Launches in 2023: largest therapy area
- immunology biosimilars
- 80 total launches, surpassing 2021 and 2022
- attributed to Q3 influx of humira biosimilars and RSV vaccines
Speciality use
- today, over 1/2 of spending is on speciality
- shifting from lower cost to biologics/specialty pharmacy
Top 3 growing therapy areas since 2019
- immunology/allergy
- endocrinology (GLP-1s)
- oncology
Biosimilar Competition
- nearly half of immunology biologic volume is facing biosimilar competition, which has lead to icnreased use
Speciality medicines will represent about ___ of global spending in 2028 and ___ of total spending in leading developed markets
43%, 55%
Exclusivity losses
will reach 192 billion over the next 5 years with 30% due to the availability of biosimilars
obesity and managed care
global obesity spending has accelerated in the past 2 years from novel drugs with a significant upside if more widely reimbursed, forcasted to increase
cell and gene therapies vs RNA
have differing spending outlook and large uncertainties while RNA therapies have the largest potential
top paid class in indiana
behavioral health in adults and children
top drug by class
- inflammatory disease: humira
- diabetes: ozempic
- asthma/copd: dupixent
- behavioral health: vraylar
health service utilization index in Q4 2022
100: operating at pre-covid levels with shifts in utilization
office, institutional, and telehealth visits
108
screening and diagnostic tests
89
elective procedures
98
new prescriptions
104
Doctors visits in 2020
- almost 1 billion diagnosis visits that did not happen
- 18.8%
antibiotic use and rising antimicrobial resistance
- 2.4 billion antibiotic days of therapy in 2022
- 7% down from pre-pandemic
- use in children and older adults up 8%
stimulant use and related shortages
- adhd grow 11% over the last 5 years
- women aged 20-64 now account for 33% of prescriptions, up 27% in 2018
mental health in young peopl
- reached 567 million in 2022, up 9% since 2019
- girls under 19 up 33% since prepandemic
GLP1s
- over 500k new prescriptions, up 152% in february 2023 compared to prior year
Combating the opioid overdose epidemic
- per capita opioid use down 64% since peak in 2011
- deaths up 253% since 2011
Gaps in women’s health
- contraception use down 6% in 2022
- lower use of long-acting birth control
weight loss drug use
increased with added to coverage in commercial HMO
Amazon Telehealth
- piloted in 2019 for employee health plan
- chat or video conference
- in person care
The us uses more health care services than peer countries
false, has fewer physician visits and days spent in the hospital
the US has too many specialists and not enough pcp
false, mix in the US is similar to other countries
the US provides too much inpatient hospital care
false, 19% is spent on inpatient services
US spends too little on social services
false, does spend a little less, but not an outlier
quality of healthcare is much lower in the US
quality of care in the US isnt markedly different than others
main drivers of higher health care spending
high prices for salaries of physicians and nurses, pharma, medical devices, and administration
high utilization of healthcare services and low spending on social services
do not play a significant role in higher US healthcare costs
quality of healthcare
despite poor pop health outcomes, quality once people are sick is high in the US
Better outcomes for what disease
heart attacks and strokes
worse outcomes for what
diabetes and asthma avaoidable hospitalizations
healthcare spending per capita in US
- largest compared to any coutnry
- mostly inpatient and outpatient
MRIs
cost 10x more in the US than switzerland
Humira and Enbrel
humira is 2.5x higher per month in the US than Japan, enbrel is 4x more in the US vs japan or france
hep c treatment
15-30k a month in the US, free to other parts of the world
If someone has health insurance, all medical expenses will be covered
false
employers typically pay 25-30% of total annual salary for benefits
true
people need health insurance because healthcare is expensive
true (expensive and unpredictable)
Fully Insured Health Plan
- insurance company assumes risk of providing health coverage for insured events
- employer pays a per-employee premium to insurance company (i.e. $500/employee)
- usually offered by smaller employees
self-insured health plans
- employer assumes risk of providing health coverage for insured events
- employer acts as own insurer
- claims often processed by an insurance company
- usually offered by larger employers
benefits of self-insured plan
- control and flexibility
- allows customization of plans vs one size fits all
- employer is free to contract with any provider
- employer does not have to pre-pay for coverage
- avoids state-mandated benefits
- potential decrease in cost
- control –> maximizes income
- avoids state health insurance premium taxes and some other fees
disease prevalence at purdue
HTN is the most common disease state
those with the more rare diseases are more likely to access health care system
purdue healthcare expenditures increase
% increase per year has decreased
purdue healthcare cost split
- 84%/16%
- 80/20 mandated by january 2014
- moving toward industry standards of 75/25
geography influence on cost
- cost of procedure differ per location
- us more expensive
purdue short term strategy to decrease cost: insurance plans
- two tier premium structure
- deductible/coinsurance arrangement
- offer preventative generic Rxs at not cost
- combine Rx and medical deductibles
purdue short term strategy to decrease cost: encouraged consumerism
- develop lab and imaging benefits
- implement castlight rewards (incentive for choosing the lowest cost/highest quality provider)
- adjust center for healthy living
purdue short term strategy to decrease cost: wellness campaign
incentivize improving wellness outcomes
purdue long term strategy to decrease cost: stage 1
- awareness
- develop metrics
- develop brand
- develop or identify champions
- assess funding
purdue long term strategy to decrease cost: stage 2
- engagement/accountability
- share stories
- education
- partner with local providers
- create penalty or rewards system
- evaluate metrics
purdue long term strategy to decrease cost: stage 3
- evaluate outcomes
- add new incentives
Center for Healthy Living at Purdue proposal
- the provision of collaborative drug therapy and medication therapy management by pharmacists
Center for Healthy Living at Purdue potential
- over 4,600 faculty/staff that take ≥ distinct medications
- > 10% covered lives have DM, HLD, HTN, and/or asthma
pharmacy strategies cost savings
median benefit to cost ration of 2.89 in outpatient setting
pharmacy strategies productivity
- 50% reduction in missed work hours for employees with DM
- 400% reduction in missed work hours for employees with asthma
pharmacy strategies health outcomes
- CMS measures
- NQF measures
how have health and wellness programs impacted employees
improvement in disease state
health insurance is a ______ responsibility for cost and outcomes between employer and employee
shared
should consumers be educated to use health care wisely?
yes
do pharmacists have significant role in cost containment strategies
yes
Political Influences on VA
can be significant
how does the VA recover their revenue
through third party billing (exception: medicare)
Va customers
- must have served at least 2 full years of active duty
- spouses/dependents not generally covered
- income component to elligibility
Veteran population projectiosn
projected to decline due to shrinkage of baby boomers
which population makes up most of the VA population
baby boomers
Minority and female veteran population projections
projected to increase
VHA organizational structure
- 18 regional networks
- 171 medical centers of varying complexity
- > 1400 outpatient clinics
VA funding
- primarily federal income taxes
- funding distributed using VERA (veterans equitable resource allocation)
Rx fulfillment at VA
- nationally integrated EMR
- computer prescriber order entry including C-IIs
- significant opportunity for cost-saving initiatives
- follow federal pharmacy regulation (not necessarily state laws)
- pharmacists can be licensed in any state
mail order pharmacy services at VA
- primarily for refills
- highly automated operation
have the capacity to fill all but C-II Rx - lower overhead costs due to economies of scale
Medication Care Management at VA
- pharmacists practice in a variety of direct patient care settings
- treated as mid-level practicioners
- credentialed through medical staff process
Medication Management of veterans
- full review of all medications with each fill allowed by integrated medical record
- every veteran is counseled on new prescriptions prior to dispensing
- formulary substitutions and conversions allowed w/o MD approval
- quantities may be adjusted by pharmacists
- supply items provided by pharmacy
VA National Formulary
- closed formulary
- searchable national formulary
- national p&t committee using evidence-based medicine
- national contracts to leverage cost containment
- pharmacy managed therapeutic interchanges are common based on contract modifications
- risk sharing agreements
Veteran Copays
- based on service connection and tiers
- no copays for conditions directly linked to time in the military (diabetes and agent orange)
Provider or Payer: VA
- uniquely serves as the healthcare provider and payer
- nonformulary requests entered by prescriber, adjudicated by va pharmacist and decision made
MISSION act
- expanded and redefined the circumstances in which veterans can receive medical care outside of the VA
- increase in outside Rx
- urgent and emergent prescription fills
- workflow more akin to community pharmacy
MISSION Act circumstances
- service not available at a VA medical
- veteran lives in a US state or territory without a full-service VA medical facility
- grandfather provision related to distance eligibility for VCP
- best medical interest of the veteran
- service line does not meet certain quality standards
supply chain
- network between a company and its suppliers to produce and distribute a specific product to the final buyer
- interconnected journey that raw materials, components, and goods take before their assembly and sale to customers
- a system of organizations, people, activities, information, and resources that provides products or services to customers
how does drug flow to a patient
- raw material sourcing
- manufacturing
- distribution and logistics
- dispensing
role of manufacturers
- set initial product price
- negotiate price discounts based on market share, volume, payment and demand
- contract with GPO, PBMs, wholesalers/distributors and directly with providers
wholesalers and distributors
- purchases product from manufacturer
- distributes to variety of providers
pharmacy role
- contracts with wholesaler for price below initial manufacturer price
- collects copay from patients
PBM role
- negotiate drug prices for payers and receive rebates from manufacturers
- insurers and employers pay PBMs to manager drug benefits
- make purchasing decisions
- move marketshare by selecting one manufacturer
- take title of product
hospitals role
- purchase from GPO contract or directly from manufacturer
- work with GPOs to develop contacts or directly with manufacturer
GPOs
- leverage buying power of providers to secure discounts
- negotiate to with manufacturers on behalf of providers
- generally owned by providers
- no markups, added fees, or hidden costs
- fees are highly transparent to providers
- do not take ownership of physical product
Class of Trade
- the type of distribution channel by which pharmaceutical products flow into the consumer market
- type of customer
- no standard definition of COT exists
What goes into determining COT
- product. type
- drug reimbursement
- patient location (acute vs non-acute)
- utilization
- market segment
- prescriber control or ownership
who determins cot
the manufacturer
Generic Injectables
- generics with one or more sources
- segment hit hard by drug crisis
generic non-injectables
- 5K generic pills, orals, and topicals
branded non-contract
- no therapeutic alternatives, nearly all customers pay same price
- monitor and identify lifecycle opportunities
branded contract
- therapeutic alternatives motivate suppliers to grow an protect market share
Which pharmaceutical spend category represents the largest opportunity for contracting
- generic injectables
What is a GPO?
- help aggregate and leverage purchase volume to negotiate discounts with manufacturers and distributors
- the GPO never takes possession of the product
- members still have a choice
What are some example data can be leveraged in the supply chain space?
- usage data
Descriptive analytics
- what happened?
- inventory trends
- ROI
- usage
diagnostic analytics
- why did it happen?
- shipment delays
- order fulfillment
- inventory turnover
predictive analytics
- what will happen
- raw material tracking
- inventory management
- pricing
- competitiveness
prescriptive analytics
- what shall i do
- market intelligence
- strategy guidance
estimated drug price inflation rate
3.80%
idea state of data flow
data flows upstream and downstream
current state of data flow
minimalistic upstream and downstream data sharing. limitations to requirements
largest cause of drug shortages
unknown/would not provide
HC Industry and Climate Change
- HC sector is responsible for 8.5% of the country’s greenhouse gas emissions
impact of climate change on healthcare
- increased heat-related illnesses
- worsening of air quality (resp and CV disease)
- spread of vector borne diseases
- food insecurity and malnutrition
- mental health impacts
- increased allergies and infectious diseases
- healthcare system strain
- displacement and migration
- social inequities
children as vulnerable populations : climate change
- breathe more air and drink more water per body weight than adults
- developing organs and low immunity
- dependent on adults
- more time spent outdoors
older adults as vulnerable populations : climate change
- low immunity
- pre-existing conditions
- limited mobility
communities of color as vulnerable populations : climate change
- structural racism
- inadequate infrastructure
- health disparities
- lack of social capital
- language barrier
- increased heart and lung complications
low income communities
- less resources and means to evacuate
- inadequate infrastructure
Rare hematology integration lead
- develop medical evidence generation strategy and tactics for rare hematology
