Increasing Value in Managed Care Practice Flashcards
What is a managed care organization (MCO)?
Organizations which utilize techniques to provide health care in a COST-EFFECTIVE manner.
AKA health insurance plans
What is the difference between Staff model and Independent Practice Association (IPA) model MCOs?
Staff Model = physicians/clinics/hospitals EXCLUSIVE to enrollees
IPA model = MCO contracts with independent providers into their preferred provider organization (PPO)
What are 4 types of MCO plans? (Aka how do people get coverage?)
Medicaid
Medicare
Employer-offered commercial plans
Self-funded plans
What is the “triple aim” of MCOs?
Improve:
QUALITY of life
Patient SATISFACTION
AFFORDABILITY
What is the organization that “measures” MCOs for quality?
Health Plan Employer Data & Information Set (HEDIS)
What do PBMs do?
Claims processing
Assist with formularies
Review prior authorization requests
Pharmacy network administration
______ dollars spent n prescription drugs in the US
400 billion!!
How do drastically increasing prescription costs affect patients?
Increased insurance premiums
Increased copay costs => decreased adherence!
What drives up drug utilization?
Improved technology (causes MORE, BETTER diagnoses!)
Guideline changes over time (usually dont consider cost, only clinical effect)
How do drug manufacturers influence the drug market and utilization?
Manufacturers are free to set pricing at any number!
Price increases happen annually
Historically there have been very few interventions from government (have to face lobbying)
What is patient solicitation?
Pharma manufacturers put out lots and lots of advertising DIRECTLY to consumers to influence prescribing.
Drug coupons reduce costs for patients but increase overall medication cost (money comes from here!)
WHO is the biggest influencer of drug costs?
PBMs!
(Few, large PBMs have lots of negotiating power, demand high rebates)
What are ACCELERATED FDA approvals?
Pathway for companies to get unique medications to market faster
Drugs MAY NOT be as efficacious as anticipated
How do MCOs manage medications?
Formularies
Benefit design
Utilization management
Drug Utilization Review (DURs)
Specialty medications
Generics
MTM
Price transparency
Disease management programs
Rebates
What is the difference between open vs closed formularies?
Open = all drugs are technically available
Closed = only listed drugs are available
What is a P&T Committee?
Pharmacy & Therapeutics (P&T) Committee is comprised of practicing physicians and pharmacists
Develops the formulary tiers, recommend utilization
Meet quarterly to review newly approved meds
Review coverage of drug classes routinely to ensure cost-effectiveness
Ensure no biases
What are the major factors that the P&T committee consider? What is the NUMBER ONE objective?
SAFETY and EFFICACY
The NEED for the drug
EFFECTS on clinical outcomes
Multiple products in a class
Physician ACCEPTANCE
OBJECTIVE = overall cost effectiveness
What are the formulary tiers?
Tier 1 = generic drugs, preferred!
Tier 2 = brands w clinical advantages, $$ first line therapies, unique approved therapies
Tier 3 = me too drugs, non-preferred drugs
What are some ways to affect the actual insurance plan costs?
Reduce coverage
Increase employee contribution aka premium
Shift to incentivized benefit design (ie. Tiered formularies)
Coinsurance (% copay instead of flat cost)
Min/Max per prescription
High deductibles
Out of pocket maximums
What are prior authorizations?
Basically a petition to get a non-preferred drug covered
Paperwork must be submitted by provider
Helps verify appropriate use and safety
Usually turnaround is <24 hrs
What is step therapy?
Requires patients try certain preferred medications before insurance will cover a different non-preferred agent
What are quantity limits and why are they used?
Limits number of drug allowed to be billed
(May be limited per fill, time period, or per lifetime
Either due to package size or clinical limits (ie. Abx should only be used short term)
What is diagnosis editing?
Uses medical claims data to automatically review claims for appropriateness in real-time
Helps curb inappropriate use
MOSTLY FOR GLP1 DRUGS TO PREVENT USE FOR WEIGHT LOSS
What is a retrospective DUR?
Review of past claims history to identify concerns
- opioid/benzo use
- indications for high dose opioids
- gaps in antipsychotics or HIV therapy
What kind of medications are usually specialty meds?
Biotech products that target patients with complex therapies
What are some considerations for specialty medications?
May have coverage under either medical benefit or prescription drug manufacturer
May require additional dose/ side effect monitoring, administration help
Management of OFF LABEL use with clinical evidence
Which is more expensive, pharmacy benefit (patient administered) or medical benefit (clinician administered) specialty meds?
PHARMACY benefit (PATIENT administered) specialty meds cost more! Fastest rising portion of Rx cost
(Medical benefit/clinician administered costs is usually from cancer-related treatments)
What is the name of the policy that forces patients to use generic drugs before brands?
Generic First Policy
What are biosimilars?
A biologic drug that is nearly identical to an existing biologic drug
AKA similar but not equivalent to generic
(Potential for savings but not substitutable at pharmacies!)
What is academic detailing?
Providing prescribers with cost vs efficacy data (including medical costs)
Counteracts any misleading advertising from manufacturers
What is MTM?
Medication Therapy Management
- CMS requires insurers to have an MTM program in place of Medicare D
- Complete annual review of medications and quarterly follow ups
Complex drug regimen patients have better outcomes with MTMs
