Managed Care Flashcards

1
Q

Managed care definition

A

generic term for various healthcare payment systems that attempt to contain costs by controlling the type and level of services provided to help manage the care of a patient

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2
Q

traditional insurance

A

emphasis on treatment, patients pay and providers of health care get paid at least a portion of a test or treatment they deem necessary for a patient- fee for service

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3
Q

managed care insurance

A

more emphasis on prevention, attempt to contain costs, provider networks contract with insurance companies about the types of services to be provided and the payment to be received

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4
Q

Health Maintenance Organization (HMO)

A

providers paid a set amount per month per patient that they see (per-member per-month) capitation, set regardless how many times the patient sees the physician, goal to keep patient healthy, PCP “gatekeeper” who coordinates care and authorizes referrals to specialists - care is only in a certain network

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5
Q

preferred provider organization (PPO)

A

patients free to see any provider that they choose, cheaper to see in prefferred network, do not have a gatekeeper, fee-for-service model, patients pay for care when its recieved

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6
Q

Point of Service (POS)

A

hybrid. Gatekeeper like HMO, pay more to see someone outside of the network PPS

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7
Q

Prior Authorization

A

promote safe and effective appropriate use of selected drugs. involves: proper patient selection, dosage, drug admin, duration- drug claim has to be authorized in order to go through - request reviewed by the PBM

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8
Q

step therapy

A

encourages cost-effective drugs when appropriate, member may need to try alternative first (generic) - physician needs to provide prescription for alt drug if they think it will work better

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9
Q

quantity limits

A

quantity limitation on refills - how much of a drug can be received with each prescription

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10
Q

roles of managed care pharmacists

A

plan design, cost management, clinical program development , communication, patient safety

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11
Q

managed care pharmacists promote clinical safety

A

DUR programs, PA programs, fraud and abuse programs, monitoring programs

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12
Q

specialty pharmacy drugs

A

treat serious or chronic medical conditions (MS), high costs, Risk Evaluation Mitigation Strategy

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