Part 3 Flashcards
What is the NIH
National Institute of Health
What is the NIH for
Government agency for biomedical research
What department is the NIH under
Department of Health and Human Services
What does the NIH fund
Clinical trials through tax payer dollars
What is the Institute of Medicine responsible for
The to err is human report
1. Sheds light on health care errors
2. Puts blame on systems not individuals
What is AHQR
Agency for Health Care Quality and Research
What does AHQR create (SBEAA)
Improvements in health care by making it
1. Safer
2. Better
3. Equitable
4. Accessible
5. Affordable
What department is AHQR under
Department of Health and Human Services
What is the NQF
National Quality Forum
What does NQF focus on?
Health care system as a whole
(Whole NQF)
What does NQF create and support
Methods and training programs that save lives
What does NQF endorse
Healthcare standards and quality measures
What is CMS
Centers for Medicare and Medicaid
What department is CMS under
Department of Health and Human Services
What 3 health care programs does CMS administer
- Medicare
- Medicaid
- Health Insurance Marketplace
When do patients become eligible for medicare
- Age 65
- Disability
- ERSD - end stage renal disease
- ALS - Lou Gherigs
What does Medicare A cover
- Hospital Benefits
- Skilled nursing facility under certain circumstances
What 5 things does Medicare B cover
1.clinical and preventative care
2. DME
3. Nebulizer/diabetic testing supplies/drugs delivered by pumps
4. Most Vaccines
5. Drugs for end stage renal disease ESRD
Another name for Medicare part c
Medicare advantage plans
What does Medicare part c include
Both parts A and B
What are additional benefits that may fall under medicare part c
- Prescription drugs
- Vision
- Dental
Explain Tiers of Medicare part D coverage
Tier 1 - little to no copay (generic drugs)
Tier 2 - preferred brand name drugs
Tier 3 - non preferred brand name drugs
Specialty tier -specialty drugs ie biologics
Most vaccines are covered under part b what vaccine is covered under part d
Shingrix
6 classes of drugs not covered by part D
- Benzodiazapines
- Otcs
- Barbiturates
4.fertility - Weighloss/weight gain
- Hair growth
What 6 drug classes are protected under part d and must cover the majority or all of these classes
- Seizure drugs
- Antidepressants
- Antipsychotics
- Oncology
- HIV
- Immunosuppressants
How long do Medicare records need to be kept
10 years
What is Medigap
Private insurers that cover out of pocket costs not covered by Medicare (generally does not cover the donut hole)
What does MTM stand for?
Medication Therapy Management
What 3 things make a patient eligible for MTM through Medicare D
- Annual drug expense of x amount of dollars (usually 4 to 5 thousand)
- Min of 2 to 3 chronic diseases
- Min of 2-8 part d covered drugs
Billing code for initial 15 minutes of a new patient
99605
Billing code for the 1st 15 minutes of and established patient
99606
Billing code for the next 15 minutes for both established or new patients
99607
What to bill if met with an established patient for 45 minutes
Bill 1 unit of 99606 and 2 units of 99607
What does CMR stand for
Comprehensive Medication Review
CMR MTM must be person to person by one of which three methods
- Face to Face
- Telehealth
- Phone medication review
What is the purpose of CMR
- Improve pts knowledge of medications
- Assess medication therapy (including otc rx and herbals)
- Identify problems
- Create a plan to fix those problems
Recommended format for CMR documentation
- CL - Cover Letter
- MAP - Medication Action Plan
- PML - Personal Medication List
How often can a CMR be billed
Annually
Difference between a targeted medication review and a CMR
Less intensive
Down for a specific reason ie new new med is started
How often can a targeted Medication Review be billed
Quarterly
What is REMS
Risk Evaluation and Mitigation Strategy
What is the goal or REMS
Ensure the benefit is greater than the risk
Examples or REMS meds
- Accurate - I pledge
- Clozaril- online registry
Drug sponsors develop REMS, who reviews and approves it
FDA
Why must be given to patients of an REMS drug
REMS Medication Guide
Given in addition to standard patient education
Before a REMS drug is assigned, what must be completed
A time table for assessment
What is ETASU
Elements to Assure Safe Use
What is ETASU part of
REMS program
What is ETASU
Required tasks for health care professionals
When does ETASU need to be completed
Prior to prescribing or dispensing
Examples of ETASU
- Specialized training
- Drug to only be given in a certain setting
- Lab tests may need to be done prior to dispensing/prescribing
