Lecture 9

Question 1

true or false

managed care is the new healthcare

Answer 1

true

Question 2

managed care includes managed care organizations such as….

Answer 2

aetna, signa, kaiser

Question 3

what are ACOs

Answer 3

accountable care organizations

Question 4

are managed care organizations physical entities?

Answer 4

yes

Question 5

true or false

managed care is 100% privatized

Answer 5

true

Question 6

managed care organizations offer ______

Answer 6

MCPs (managed care plans)

Question 7

what are managed care plans?

Answer 7

insurance policies offered by MCOs purchased directly (through marketplace) or indirectly (through employer)

Question 8

pharmacists may work in managed care organizations as _____

Answer 8

PRACTITIONERS
(when working for HMOs, PPOs, etc)

Question 9

true or false

pharmacists working for HMOs and pharmacists working for retail or hospital have essentially the same roles —- dispensing and clinical roles

Answer 9

true

Question 10

explain what accountable care organizations are

Answer 10

goes hand in hand with medicare. closely or loosely knit providers coming together to form a network of providers to provide high quality care to a designated group of patients

when NOT associated with r medicare, it’s called patient centered medical homes (PCMH)

Question 11

are patient centered medical homes nursing homes?

Answer 11

NO

Question 12

what law gave us ACOs?

Answer 12

obamacare

Question 13

medical homes and ACOs are a network of _____

Answer 13

PROVIDERS

Question 14

what does PPO stand for

Answer 14

preferred provider organizations

Question 15

true or false

patient centered medical homes existed before obamacare

Answer 15

false

Question 16

patient centered medical homes are a ____ based approach

Answer 16

TEAM

Question 17

patient centered medical homes are focused on what kind of care?

Answer 17

PRIMARY CARE (like dr clinics)

Question 18

to use a PCMH, does your insurance have to pay for it?

Answer 18

not necessarily, but they’re very expensive out of pocket. you technically can still use them if not in network

Question 19

is pharmacy practice common in PCMH’s?

Answer 19

not very common, but it’s growing

Question 20

explain what a case manager is and their responsibilities

Answer 20

similar function to hospitalists

primary function is COC — coordination of care in medical home. 1 person taking responsibility for a group of patients and coordinating care for them. they take care of every aspect —financial, administrative, logistics, scheduling, etc

many are healthcare professionals like nurse practitioners

Question 21

true or false

pharmacists who are case managers or hospitalists can call themselves managed care pharmacists

Answer 21

true

Question 22

what is the difference between pharmacists who are case managers and pharmacists who are hospitalists

Answer 22

the patients of case managers are primary care (PCMH)

the patients of hospitalists are inpatient care

Question 23

true or false

pharmacists working for PBMS are in a traditional pharmacist role

Answer 23

FALSE — not doing dispensing or clinical

it’s called operational aspect — designing drug benefits, making formularies, etc

Question 24

who are the 3 major clients of PBMS

Answer 24

employers
health plans
pharmacies

Question 25

who are the “big 3” PBMs?
they account for ____% of the 5 billion spent on prescription drugs

Answer 25

CVS caremark/aetna
express scripts
optum/united healthcare

80%

Question 26

does any other country have PBM?

Answer 26

no

Question 27

PBMs started when? when did they become popular?

Answer 27

started in the 60s, got popular in the 90s (when AMCP started)

Question 28

what are GPOs?

Answer 28

group purchasing organizations

pool individual orders from independent/smaller pharmacies

Question 29

what is awp?

Answer 29

average wholesaler price

benchmark # that PBMS use to compensate pharmacies

“sticker price” not really a reliable number

Question 30

what does MSRP stand for

Answer 30

manufacturer suggested sticker price

Question 31

what is the red book?

Answer 31

alphabetical list of FDA approved drug pricing