Midterm Flashcards
Population Health
the health outcomes of a group of individuals, including DISTRIBUTION of such outcomes
Studying Population Health
look at patterns of determinants
look at outcomes and quality
direct policy and research agendas
Who is responsible for overall health improvement
No on in the public or private sector currently has responsibility for overall health improvement
Factors that impact individual patients
location
insurance coverage
rare disease
language barriers
Examples of Population Health
rural vs urban
age
race
education levels
levels of health literacy
employees
Parts of the Care Continuum
Health Promotion, Wellness
Health Risk MGMT
Care Coordination/Advocacy
Disease/Case MGMT
Program Outcomes: Care Continuum
Psychosocial Outcomes
Behavior Change
Clinical and Health Status
Productivity
Financial Outcomes
Goals of Pop Health
set targets for overall population
maintain and improve health of entire population
eliminate or significantly reduce deficiencies and disparities between subgroups
Healthy People 2020 Findings
Poor or Near Poor families did not meet target objectives, however improved or no detectable change
Middle-High income met target, but had statuses that got worse
Healthy People 2030 includes _____ core or measurable objectives as well as developmental and research
355
Healthy People 2030 Objectives
health conditions
health behaviors
populations
SDOH
Relevance of Health Outcomes
relevance to policy makers and payers in both the private sector due to cost (of healthcare) an productivity (healthier people = more productivity)
Types of Groups in Healthy People 2030
Adolescents/Children/Infants/Older People
LGBTQ
Parents and Care givers
Men/Women
People with Disabilities
Workforce
Definition of Health
the capacity of people to adapt to, respond to, or control life’s challenges and changes
What is the greater focus of improving pop health?
SDOH
no amount of medical attention will help decrease the likelihood of someone developing T1DM or RA, yet both are more common in lower socioeconomic groups
Source of Potential Conflict within Pop Health
self interest of the individual vs the common good
ex: PAs, what is best for the pop isn’t what is best for the individual patient
Foundations of Pop Health: Descriptive Epidemiology
burden, course, and distribution of disease/injury
Foundations of Pop Health: Health Research Evaluation
Comparative Effectiveness Research (CER)
aims to produce the type of evidence that will assist all parties to make informed decisions to improve heath care at both the individual and population levels
Foundations of Pop Health: Evidence Based Practice
assessing the evidence using nationally recognized gu8idelines
Foundations of Pop Health: Implementation of Health Promotion and Disease Prevention Interventions
Target Audience for Direct Interventions
Foundations of Pop Health: Determinants of Health
impact of social factors on individual behaviors
income, education, employment
Foundations of Pop Health: Pop Health Informatics
collection of pop health data to assess population health, guide the provision of healthcare services and analyze health outcomes
Foundations of Pop Health: Evaluation
process, quality, and outcomes assessments
decision analysis
quality improvement processes
Claims Data
easy to obtain, standardized, diagnosis codes
Electronic Health Record Data
provides clinical clues; ease of grouping patients
Socioeconomic Data
Not frequently linked with EHR data
Patient Generated Health Data
satisfaction surveys; patient reported outcomes
prescription and medication adherence data
EHR and claims data
Examples of Pop Health Outcomes
life expectancy
mortality
premature death
cost burden
access to care
QOL indicators
quality of care indicators
unhealthy days
% reporting fair to poor health
% reporting mentally unhealthy
US life expectancy comparision
Ranked 45 with LE of 77 yoa
infant mortality is 5.8%
maternal mortality is 10%
Costs and Life Expectancy in the US
The US has a lower life expectancy than the comparable country average and pays double for health care
Drops in life expectancy causes
covid (3rd most common cause of death in 2020)
opioid overdose
Cause of Child Mortality in the US
Firearms
Population Health Mangement
optimizes health outcomes for a specific segment of a population (location, age, income, illness)
Goals of population health mgmt
preventative health
manage chronic diseases
reduce healthcare costs
Population Health Framework
strives to address health needs at all points along the continuum of health and well-being through participation of, engagement with, and targeted interventions for the population
Goal of Pop Health Framework
maintain or improve the physical and psychosocial well-being of individuals through cost-effective tailored health solutions
States with the Highest Drug Overdose Deaths Rates
OH
PA
KY
WV
DE
MD
DC
Ct
MA
NH
Which opioid is involved with the highest percentage of deaths in the last 10 years
synthetic opioids other than methadone
Difference Between Pop Health and Public Health
public health has been understood by many to be the critical function of state and local health departments such as preventing epidemics, containing environmental hazards, and encouraging healthy behaviors
major pop health determinants like healthcare, education, and income remain outside of public health authority
Pharmacoeconomics
description and analysis of the cost and consequences of pharmaceuticals and related services
process of identifying, measuring, and comparing the costs, risks, and benefits of programs, services, or therapies
determining the outcomes from the perspective of the patients, the healthcare system, or society
Why is pharmacoeconomics important?
healthcare costs increasing
healthcare outcomes are declining in the US
drugs are (and will continue to be) expensive
trade off considerations on how to spend resources
Four Types of Costs
direct medical costs
direct non-medical costs
indirect costs
intangible costs
direct medical costs
medical costs for providing treatment
ex: cost of medication, physician visits, hospitalizations
direct non medical costs
costs to the patient/family directly associated with treatment, but not medical in nature
cost: cost of transportation to clinic, babysitter, food/lodging if out of town
indirect costs
costs that result from loss of productivity because of illness or death
do not involve a transfer of money
ex: missed work or school days, decreased productivity
intangible costs
costs of pain, suffering, anxiety, or fatigue due to an illness or treatment of an illness
difficult to measure and assign value
Perspective in Pharmacoeconomics
Describes whose costs are relevant based on the purpose of the pharmacoeconomic study
Four Types of Pharmcoeconomic Analyses
Cost Minimization Analysis (CMA)
Cost Benefit Analysis (CBA)
Cost Effectiveness Analysis (CEA)
Cost Utility Analysis (CUA)
Cost Minimization Analysis
used to compare costs of interventions with equivalent clinical outcomes
generic vs brand name
drug a vs drug b assuming equal efficacy and safety
CMA Measurement Unit
dollars
CMA outcome measurement
not measured, assumed to be equivalent
CMA advantages
simplicity
no assessment of outcome
CMA disadvantages
only useful when outcomes are equal
Cost Benefit Analysis
measures costs of interventions and outcomes in monetary units
determines which intervention provides best monetary benefit (can be used to compare different drugs or services for different outcomes)
must assign monetary outcome to clinical endpoint (how much does it cost to lower BP by _____ mmHg)
CBA cost measurement unit
dollars
CBA outcome measurement unit
dollars
CBA advantages
allows comparisons of interventions with different outcomes
CBA disadvantages
requires assigning monetary value to pain, suffering, life
Cost Effectiveness Analysis
measures outcomes in natural health units (infections cured, lives saved, number of life years saved)
Determines which intervention achieves a given object at the lowest cost
most common type of analysis
CEA Comparisons
Want: Equal cost, more effective, lower cost equally effective, or lower cost more effective therapies
Incremental Effectiveness Ratio
additional cost required to obtain the additional effect gained by switching from Drug A to Drug B
ICER = (total cost of drug a - total cost of drug b)/(outcome of drug a - outcome of drug b)
CEA cost measurement unit
dollars
CEA outcome measurement
natural health unit
CEA advantages
outcomes measured in unit that are understandable to many clinicians
no need to convert outcomes into dollar amount
CEA disadvantages
outcomes must be measured in same units
length of life is not the same as quality of life
Cost Utility Analysis
measures outcomes in terms of the quality of the outcome produced
Examines cost of an intervention and the value of the outcome (Value= Cost + Quality)
referred to as utility units (patient preferences or functional status)
QALY
takes into account both the quantity and the quality of life generated by healthcare interventions
Drug A: 4 years in health state 75% = 3 QALYs
Drug B: 4 years in health state 50% = 2 QALYs
Perfect Health: 1 Utility Score
Breast Cancer: 0.80 Utility Score
Death: 0.0 Utility Score
CUA Measurement Unit
dollars
CUA outcome measurement
QALY or other utility measure
CUA advantage
accounts for quality and quantity
CUA disadvantage
not a precise measure
viewpoint may bias outcome measures
Role of a Pharmacist
evaluating pharmacoeconomic literature
applying results to clinical decision
assist in the design and implementation of research studies
Evaluating Studies
evaluate the question (should be clearly stated)
determine the perspective (should be clearly stated)
alternatives (treatments should be comparable
study design (explicit details need to be provided)
types of analysis conducted (is the title consistent with the methods)
all important and relevant costs and outcomes included
any important costs or consequences not included
was discounting utilized appropriately
are all assumptions stated
summary/conclusion
Pharmacoepidemiology
study of the use, risks, and benefits of drugs in populations
the study of utilization and effects of drugs in large numbers of people
pharmacovigilance
continual monitoring for unwanted effects and other safety-related aspects of marketed drugs
comparative effectiveness research (CER)
determining what therapeutic intervention (not just drug products) works best for a given disorder in a patients likely to be seen in clinical practice
pragmatic research
studies (often using randomization) that often test small practical changes that could have an impact on health outcomes
experimental
RCTs (active treatment, usual care, pragmatic)
non-experimental (observational)
case control
cohort
others
Pharmacoepidemiologic and pharmacovigilance studies are primarily what?
observational
examples of pharmacoepi studies
studies to provide estimate of probability of beneficial effects in populations, or probability of adverse effects in populations
Pharmacoepi and premarketing studies
supplements information from premarketing studies
better quantify ADRs and beneficial effects
higher precision
can include populations not well represented
can study effects of other drugs/disease states
can study effects relative to other drugs for same indication
Identifying New Info using Pharmepi
new info not available from premarketing studies
previously undetected ADRs/beneficial effects
patterns of drug utilization
effects of varied doses
economic impact of drug use
reassurance of drug safety
ethical and legal obligations
data sources for pharmepi
adverse drug reaction reports
medical claims data (private, government, insurance providers, third party vendors, diagnostic, procedure, lab, rx codes with basic patient information)
EMR
____ data sources and ______ computational abilities have more rigorous pharm epi studies possible
richer, more robust
increased
Indiana Network for Patient Care (INPC)
> 100 separate healthcare entities providing data including:
major hospitals, health networks, and insurance providers
data on > 18 million pts
clinical observation
encounter records
mineable text
prescription drug data
percent of residents who have touched the INPCR has grown to 2/3 or indiana’s pop
Bias
systematic deviation from the truth that distorts the results of research
confounding
relationship between treatment and response (or exposure and disease) is actually attributable to another variable (the confounder)
Information Bias
bias related to information regarding exposure or outcome
includes measurement and/or classification error
Detection Bias
specific outcome is diagnosed preferentially in subjects exposed to the agent
may be more likely to look for an AE in someone who is exposed to a drug
Confounding by Indication
indication for a drug or severity of disease predicts the use of the drug
occurs when the risk of an event is related to the indication for medication use but not the use of the medication itself
appears when the reason of prescription is associated with the outcome of interest
COXIBs and GI Bleeds
ACEis in preventing MI in pts with HTN (pts with comorbidities may be more likely to get ACEi)
Selection Bias
bias related to procedures used to select subjects/influence study participation
due to systematic differences in characteristics btwn those who are selected for the sutdy and those who are not
referral bias
reason for encounter is related to drug treatment
protopathic bias
exposure of interest is used unknowingly to treat adverse event related to outcome/agent is used for early manifestation of a drug of a disease that has not been diagnosed yet
antipsychotic may be started to treat delirium, but the drug may have effects that contribute to delirium
prevalance bias
prevalent cases rather than new (incident) cases are selected
Protopathic bias reverse causality
occurs if a particular treatment was started, stopped, or otherwise changed because of the baseline manifestation caused by a disease or other outcome event
drug is initiated in response to first symptom of disease which at this point is undiagnosed
lag time bias
proton pump inhibitors and fracture risk
outcome reported by pts and confirmed by medical reports after enrollment
immortal time bias
period of follow-up when, due to exposure definition, the outcome being studied could never occur
survival time, transplant studies, hospital stays and mortality
Pharmacovigilance
continual monitoring for unwanted effects and other safety related aspects of marketed drugs
historically has involved collection of spontaneous reports of drug related morbidity or mortality
Type of Data used in Pharmacovigilance
wider use of observational data conducted across multiple databases, development of large networks of observational databases
post marketing surveillance, single detection, surveillance, data mining
often involves regulatory authorities, industry
Pharmacovigilance Examples
V-safe after vaccination
fluoroquinolone (peripheral neuropathy, indications of uncomplicated UTI, sinusitis, bronchitis, cystitis, outcome reported as disability)
Types of CER
multiple study designs
- rcts with active treatment arms
- observational studies
patient-centered health research
efficacy of CER
whether a drug or treatment ha the ability to bring about a given intended effect in a controlled setting
effectiveness of cer
whether in a real-world pts and settings, a treatment in fact achieves its desired effect
Goals of CER
to inform decisions on interventions or approaches to healthcare in a real-world setting with regard to their intended and unintended outcomes that are relevant to pts
to put new treatment into proper perspective in relation to older treatment
identify pts who are more/less likely to respond to a given intervention than others
overcome external validity problems with traditional RCTs
Pragmatic research
studies (often using randomization) that often test practical changes that could have a big impact on health outcomes
pragmatic RCT
a randomized clinical trial with one or more pragmatic elements
include real world pts from diverse background
aspects of care controlled by clinician
include providers from diverse settings
comparators are those used in clinical practice
outcomes matter to clinician and patients
aims to help clinician decide between new intervention and current standard of care
What is wrong with our healthcare system?
Too expensive
$13,000 year/person
17% of GNP
Average Annual Expenditures Growth Rates for Selected Services
In 2020-2022, retail drug costs made up most of health expenditures compared to hospitals and physicians/clinics
Most total national health expenditures are spent on what service?
hospitals (30.4%)
Disconnect between ______ , _________, and ______.
What we pay, what we value, and outcomes achieved
pay more for doing more
incentives to produce better health and lacking
life expectancy, infant mortality, maternal mortality, does not measure up
US compares ______ to other industrialized countries
poorly
Top preforming countries
- provide universal coverage and remove cost barriers
- invest in primary care systems to ensure high value services are equitably available in all communities to all people
- reduce admin burdens that divert time, efforts, and spending on HC improvements
- invest in social services, especially for children and working age adults (access the HCS the least, where we can improve the most)
Too much is spent for __________ and at __________ without clear benefit
older patients, end-of-life
Those age 18 and younger are the _______ of the total population and utilize the ________ amount of total health spending
majority, least
A _______ percentage of the population consume the _______ resources
small, most
Why do drug companies charge higher prices?
because they can
Lack of ______ with respect to cost in the US
transparency
Access issues to healthcare in specific populations
PCP per 10k patients
poor and rural
geography
average costs of annual health insurance premiums
southeast
Equity issues
adults with below average income have poorer access to healthcare, less timely care, and less engagement with providers
______ people spend more on healthcare
white
population with the highest % of adults who delayed or did not get health or dental care due to cost
Uninsured
hispanic
worse health status
urban (by 1%)
too ______ PCPs. _________ distributed, __________ reimbursed
few, poorly, poorly
_____ of care coordination in the US
lack
Healthcare ________ is very powerful
lobby
public health has been historically _______ and thought to be a _______ responsibility
underfunded, local
Individualism in the US
most individualistic country on earth
high on indulgence, short term thinking, masculinity
most patients are ________ or _________ about their healthcare and associated costs
misinformed, poorly informed
Managed Care Organizations
often focus on decreasing utilization of healthcare services and certain medications across the board vs target use
decision makers are not associated with the patient’s care
Health care costs for employers and employees
increasing costs for both
employers have been shifting more costs to employees (deductibles and co-pays)
Waste in the US
unnecessary care
care outside of standards and guidelines
fraud
providers’ time due to administrative duties (prior authorizations)
How should we measure healthcare?
quality
access
efficiency
equity
healthy lives
Who is uninsured?
young, latinx/hispanic, poor, sicker, living in the south
Health Insurance: 1920s
some hospitals offered services on pre-paid plan
Health Insurance: 1929
first employer-sponsored plan was created by teachers in dallas, TX
Health Insurance: 1935
social security act: no health coverage
WWII impact on insurance
employer sponsored plans as benefit dramatically expanded as a direct result of wage control
Health Insurance: 1946
Hill Burton Act: hospital construction
Health Insurance: 1948
president truman proposes national health insurance
Health Insurance: 1954
tax deduction for employers in the revenue act
Health Insurance: 1965
Medicare, Medicaid, self employed who had to buy their own insurance through exchanges (ACA)
Goals of the ACA
improve accessibility to coverage
decrease the number of uninsured
improve efficiency of providing care
improve quality of care
decrease cost of care
30 day readmission penalties
review of the data indicates 75% of readmission are preventable
ACA penalizes hospitals for excessive readmission rates
(AMI, CHF, pneumonia, knee/hip, COPD)
Lyndon B Johnson’s Impact on Healthcare
Medicare and Medicaid
7/30, 1965
Medicare
health insurance for the elderly (≥65 yo), disabled, ESRD, ALS
No dental or eye benefits
No drug benefits for outpatient
Medicare Part A
covers hospital costs
no premium costs
SNF care (max 100 days)
some home health care, hospice
Medicare Part B
-premium costs deducted from SS
covers physician costs, not required
medical supplies
drugs admin in MD offices
Medicare Part C (Medicare Advantage)
parts A + B+D (may cover broader list of services
managed care (private insurance companies)
Medicare Part D
drug benefit
premium costs deducted from SS
Enrolling in Part A
begins 3 months before 65th birthday (do not need to be retired)
do not have to enroll as long as you have a comparable insurance plan
starts when you start receiving SS benefits
most people receive Part A for free
penalty for late enrollment, impact on part B
What is not covered by Part B?
long term care
dental care
cosmetic surgery
eye exams for prescribing glasses
routine foot care
hearing aids and exams
acupuncture
Billing Medicare: Where will medications be used?
A: in hospital
B: doctors office
D: at home
Billing Medicare: What will the medications be used for?
D: po methotrexate for arthritis
B: immunosuppressive/cancer treatment
Billing Medicare: How will it be used?
B: insulin B for pump
D: syringe
Medigap-Medicare Supplement
not administered through CMS but standardized by Federal law
picks up deductibles for part A
picks up deductibles and copays for part B
standard options in each state
purchased through private companies
Medicare Part C: Managed Care
also called medicare advantage plans
PAs very common
recently aggressively advertised with greatly expanded list of services
premiums, deductibles, networks , optional services
increasing amount of enrollees over the years
Features of Advantage Plans
administered by private companies but the beneficiary is still considered enrolled in Medicare
premiums or the costs of services (co-pays and deductibles) can be lower than they are in original medicare or original medicare with a medigap policy
they may offer extra benefits including vision and dental
coordinate your care, fewer choices
Medicare STAR Rating System
used by CMS to measure how well Medicare Advantage and Part D plans perform
plans reviewed annually
1 to 5
rated on how well plans perform in certain categories
Medicare Part D Impact
largest change in insurance processing in retail pharmacy history
run by private insurance companies, but CMS sets minimum standard
not a single entity, beneficiaries need to voluntarily enroll and select a plan
formularies for each plan are different
program never funded
History of Medicaid
health insurance for the poor and medically indigent of all ages
not required by states
managed by state government
wide variation in the quality and range of services in various states
Medicaid Milestones
2014: allows people with income up to 138% of FPL to qualify, expansion due to ACA
Nationally, Medicare is _________ to private insurance for access to care
comparable
Medicaid per enrollee spending is significantly greater for which populations
elderly and individuals with disabilities (long term care> acute care)
Medicaid drug spending and rebates
more money coming back as rebates than what is spent
Medicaid in Indiana
Adopted
children and pregnant women mostly enrolled
Medicaid not adopted in what region?
southeast mostly
Who qualifies for medicaid?
low income families who meat certain state requirements (<138% of FPL in IN)
infants born to medicaid eligible pregnant women
children < 6yo and pregnant women with incomes < 138% FPL (IN, <158%)
pregnant mothers are covered for 12 months after pregnancy ends
certain medicare beneficiaries
True/False: Most Women Covered by Medicaid Work Outside of Home
true
Hoosier Healthwise
children and pregnant women
Hoosier Care Connect
> 65 yo not eligible for Medicare;blind;disabled
Traditional Medicaid
> 65 eligible for Medicare LTC; home ore community-based waiver services
Healthy Indiana Plan (HIP)
low income adults 19-64 with income <138% FPL
Mandatory Services of Medicaid
LTC, hospital, physician, home health, prenatal care, family planning services
Optional Services of Medicaid
pharmacy, dental, ICF for mentally retarded, mental health rehab
Eligibility of Medicaid
1/3 of all children are insured through medicaid
while children are eligible for dental coverage, few dentists participate
aca provides eligibility for most low-income adults <65 with incomes <138% FPL
Medicaid Reimburssement
100%
American Rescue Plan
people up to 150% FPL can now get silver plan at zero premium and lower deductibles
incentives for more states to expand Medicaid coverage
subsidies for rural providers adversely impacted by COVID
require the government to negotiate prices for some drugs covered under part B and part D beginning 2026
require drug companies to pay rebates to Medicare if prices rise faster than inflation for drugs used by Medicare beneficiaries
cap out of pocket spending for Medicare Part D
Adherence to ART Therapy in North America vs Africa
Higher adherence in north Africa
Importance of non-clinical factors
40% of non clinical factors are socioeconomic factorsP
Provision of care for children with type 1 diabetes in africans vs europeans
lower in africa than in europeMP
AMPATH impact
started nutrition program to western africa lowered weight, cholesterol, bp, diastolic bp, ldld, triglycerides
started partnership with USAID to address HIV epidemic
Where do transitions of care occur?
anytime a patient moves from one level of care to another
ER to community services
Why are transitions of care important for patients?
address an expectation of continuity of care, especially within a healthcare system
Why are transitions of care important for hospitals?
reimbursements are tied specifically to readmission
cost avoidance
Why are transitions of care important for insurers?
cost avoidance
improved outcomes
Accountable Care Organizations (ACOs)
groups of hospitals, providers and community partners who come together along with a health plan to improve patient outcomes and reduce health care costs by delivering highly coordinated care
addresses SDOH
reduce preventable hospital admissions
better manage medications
avoid unnecessary trips to ER
Patients for whom transitions of care services are especially important?
elderly
patients living alone
patients with caregivers
patients with complicated therapies
patients with limited health literacy
patients without a PCP
patients with comorbid psychiatric illness or SUD
what can go wrong without good transitions of care
wrong medications, diagnosis, treatment
delay in treatment
duplicate tests, medications, or treatments
increased costs
patient/caregiver confusion
reduced satisfaction
poor outcomes/treatments not adhered to
slower recovery
patients lost to follow up
How soon should follow up occur following discharge?
within 48 hours
how soon should one follow up after discharge from the hospital to address medication related issues or efficacy of discharge medications?
1-2 weeks?
Distribution of US Population by Race/Ethnicity
By 2050, white, non hispanic population % is projected to drop, while asian, hispanic, and other population % projected to increase
Coverage, access and use of care among people of color compared to white people
mostly worse
Uninsured rates among the non-elderly population by race/ethnicity
higher rates in AIAN and hispanic populations
Life expectancy in years by race/ethnicity
lowest in AIAN
Infant mortality and maternal mortality worse in which population
black
highest death rates for diabetes by race/ethnicity
NHOPI (native Hawaiian or other pacific islander)
AIAN
Black
SDOH among people of color
worse for black and hispanic people compared to white people
Educational Attainment by race/ethnicity
worse in AIAN and NHOPI
True/False: nearly half of health care workers have witnessed discrimination against patients
True
especially black HCWs, HCWs age 18-29
Insurance model most insured Americans have
employer-based insurance
What is managed care?
an approach to the delivery of healthcare services in a way that puts limited resources to best use in optimizing patient care
increase outcomes
decrease costs
Managed care is….
highly regionalized
molded by territorial demands
varied based on employer size
used by both private and public health plans
MCOs include
managed medicaid and medicare programs
employer-offered commercial insurance plans
department of defense TRICARE programs
integrated delivery systems and ACOs
focus continues to be on controlling costs by controlling supply and demand of the healthcare resources
utilize an array of cost management strategies to influence cost-effective decisions
HMOs
expanded following the HMO Act of 1973
promoted wellness and health prevention in addition to comprehensive acute and chronic care
limited access, limited options
Goals of Managed Care
prevention of disease
focus on wellness and enhanced QOL
improved clinical outcomes
quality and accessibility of health care
cost containment!
Managed Care Organization Definition
manage the costs and utilization of covered service and products to optimize patient care through efficient use of limited resources
Accountable Care Organizations
groups of doctors, hospitals, and other healthcare providers who voluntarily work together to provide coordinated high quality care to their medicare patients and accept financial risk/reward tied to clinical outcomes
CMS govern ACOs licenses and measures ACOs
Preferred Provider Organization
a managed care delivery model consisting of preferred networks of providers with some out of network coverage
offer patients more choice and flexibility than HMOs with correspondingly higher premiums
Covered Pharmacy Benefit in MCOs
most MCOs offer a prescription drug plan
prescription drug plans manage formularies and use utilization management tools and cost-sharing to manage prescription costs
prior authorization, step therapy, quantity limits
Tiers/Tiered Formulary
a pharmacy benefit design that financially rewards patients for using generic and preferred drugs by requiring progressively higher tiers
Tier 1
lowest copayment
most generic prescription drugs
Tier 2
medium copayment
preferred brand-name prescription drugs
Tier 3
higher copayment
nonpreferred, brand name prescription drugs
Specialty Tier
highest copayment
very high cost prescription drugs
Distribution of Health Plan Enrollment for Covered
1988: mostly conventional (low deductible)
Now: HDHP, keep plans low by increasing deductible
Limited CDHP
lowest premiums
highest deductible
highest out-of-pocket max
Premier CDHP
highest premium
lowest deductible
lowest out of pocket maximum
Average annual worker and employer contributions
as total premium costs have increased, the % paid by workers have increased
Family coverage premiums are _____ than single coverage
higher
Cumulative increases in Family Coverage Premiums, Deductibles, Inflation, And Workers Earnings
deductibles have increased the most rapidly
then, Family premiums, workers earnings, and inflation
Pharmacists in Managed Care Pharmacy
ensure the pharmacy benefit plan provides individual patients with medications that are clinically appropriate, cost effective, and delivered through the appropriate channel
Why is pop health and managed care important
overutilization of healthcare services
population living longer
greater % of population eligible for medicare and medicaid
impact of healthcare costs on federal budget
new tech driving up the costs without evidence of better outcomes
imbalance of dollars spent on a few
