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Health Care Delivery > Moral Hazzard & Managed Care Pharmacy (Exam II) > Flashcards

Moral Hazzard & Managed Care Pharmacy (Exam II) Flashcards

1
Q

What is another word for moral hazard?

A

over utilization

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2
Q

What is moral hazard?

A

the theory that the redistribution of risk (insurance) changes people’s behaviors

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3
Q

In regard to moral hazard, when insurance increases what also increases and why?

A

health care usage because people are confident that insurance will cover them

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4
Q

RAND- Health Insurance Experiment (RAND-HIE)

A

their goal is to reduce adverse selection; therefore, people will be assigned to different kinds of cost sharing

In other words, to get rid of adverse selection RAND-HIE will spread people through different options of cost sharing or increase variation of cost sharing

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5
Q

Explain the free market in relation to RAND-HIE

A

patients will pay for services through premiums like a ‘pre-payment’ for using services

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6
Q

What is provider indued demand?

A

individuals choose what or whether services to buy

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7
Q

True or False: Health care is a negative good.

A

True

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8
Q

What is utilization determined by?

A

Need

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9
Q

What is utilization not determined by?

A

Price

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10
Q

Health care delivery systems can create ____?

A

demand

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11
Q

Managed Care Pharmacy

A

evidence-based medicine to reeducate on the appropriate use of medications which would lead to better patient outcomes while lowering the over-utilization of resources

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12
Q

Who are the players in managed care? (7)

A
  1. employer groups
  2. Medicaid
  3. Medicare
  4. Physicians
  5. PBM
  6. Patients
  7. Big Pharma
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13
Q

What is PBM?

A

pharmacy benefits manager; a company that administers pharmacy benefit and design

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14
Q

What are some of the resources that PBM offers? (3)

A

manage prescription drug benefits
help make sure patients have access to safe and effective and affordable medications
decision support

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15
Q

Where do you see PBMs?

A

retail, mail, and specialty

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16
Q

What are the specific tasks of a PBM?

A
  1. manage formularies
  2. contracts with pharmaceutical manufactures
  3. offer medication therapy
  4. health and wellness programs (smoking cessation, health risk assessment, disease management)
  5. offer and design clinical programs
17
Q

Who do PBMs serve?

A
  1. insurance groups
  2. blue cross/blue shield
  3. corporate health plans
  4. government entities
  5. Third Party Administrators
  6. Medicare Part D individuals
18
Q

What are the focuses of managed care pharmacy?

A
  1. clinical programs
  2. quality
  3. medication utilization review
  4. evidence and data analytics to support decisions
  5. formulary management
19
Q

What is a drug formulary?

A

comprehensive medication list that has been to together by physicians, pharmacists, and other health care professionals to treat and diagnose diseases

20
Q

What is the purpose of drug formularies?

A

encourages use of safe, effective, and affordable medications

21
Q

Who are the formularies used by?

A
  1. Hospitals/Health Systems
  2. Employer Groups
  3. Managed Care Organizations
  4. Pharmacy Benefit Managers
  5. Government Agencies (Medicare and VA)
22
Q

What are three things that formularies accomplish?

A
  1. offer one or more therapeutic recommendations per disease state
  2. facilitates purchasing and prescribing
  3. manages cost by reducing duplication of medication
23
Q

Drug Formularies use a _____ tool with drug manufactures so drugs can be discounted.

A

negotiation

24
Q

What are examples of organizations that provide guidance for drug formularies?

A
  1. CMS
  2. AMCP
  3. ICER
25
Q

What are the two most important concepts about drug formulations?

A
  1. medications on formulary are determined by pharmacy and therapeutics committee
  2. P&T are made up of doctors, pharmacists and other professionals
26
Q

How are formularies sorted?

27
Q

What is an open formulary?

A

the payer may provide coverage for all formulary and non-formulary drugs

28
Q

What is a closed formulary?

A

non-formulary drugs are not reimbursed by the payer

29
Q

True or False: Payers will not create extra tiers to gain more memberships in certain drug classes and categories.

A

False; they can

30
Q

What are examples of extra tiers?

A
  1. Specialty Injectionable
  2. Lifestyle Medications
  3. Value Based Copay
  4. High Cost Generic Teirs
  5. Percentage copays
31
Q

What is used to determine quality?

A
  1. Medicare Part D
  2. Healthcare Effectiveness Data and Information Set
  3. Drug Safety Programs
  4. Medication Therapy Management
32
Q

Examples of Clinical Programs?

A
  1. Disease management
  2. Medication Management
  3. Adherence Programs
  4. SDOH programs
  5. Health Disparity Initiative

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