Managed Care Flashcards
Managed care definition
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
traditional insurance
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
managed care insurance
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
Health Maintenance Organization (HMO)
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
preferred provider organization (PPO)
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
Point of Service (POS)
hybrid. Gatekeeper like HMO, pay more to see someone outside of the network PPS
Prior Authorization
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
step therapy
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
quantity limits
quantity limitation on refills - how much of a drug can be received with each prescription
roles of managed care pharmacists
plan design, cost management, clinical program development , communication, patient safety
managed care pharmacists promote clinical safety
DUR programs, PA programs, fraud and abuse programs, monitoring programs
specialty pharmacy drugs
treat serious or chronic medical conditions (MS), high costs, Risk Evaluation Mitigation Strategy