Managed Care

Question 1

Why do we care about Managed Care?

Answer 1

Healthcare is expensive and increasing in expense

Question 2

National Health Expenditures per Capita in US

Answer 2

• US has continued to increase there health expenditures per capita over the years to 14,944$
• US has continued to increase there health expenditures as % of GDP over the years to 19.3%

Question 3

History of Life Expectancy

Answer 3

Female > Male

• life expectancy in 1960’s were very low around 65-72
• life expectancy began to increase throughout the years
• life expectancy from 2003 to 2020 lost two decades of progress from COVID19, opioids, and firearms

Question 4

What is Managed Care?

Answer 4

delivery of healthcare services in a way that puts LIMITED RESOURCES TO BEST USE in optimizing patient care

Question 5

Characteristics of Managed Care

Answer 5

• highly regionalized (insurance is regulated by states)
• molded by territorial demands
• varied based on employer size
• used by both private and public health plans

Question 6

What do Managed Care Organizations include?

Answer 6

• Managed Medicaid and Medicare programs
• Employer offered commercial insurance plans
• Department of Defense TRICARE

focus is on controlling costs by controlling supply and demand of healthcare resources

Question 7

Health Maintenance Organizations (HMO)

Answer 7

• expanded following the HMO Act of 1973
• promote wellness and health prevention along with acute/chronic care

Question 8

Why have HMOs fallen out?

Answer 8

• if you are apart of an HMO, you have to use HMO physician which decreases the patients choice of providers
• individuals are less likely to stay with same provider throughout their career

Question 9

Most popular HMO

Answer 9

Kaiser Permanente

Question 10

Goals of Managed Care

Answer 10

• prevention of disease
• focus on wellness and enhanced QOL
• improved clinical outcomes
• quality/accessibility of health care
• COST CONTAINMENT

Question 11

Managed Care Pharmacy Tools

Answer 11

Formulary development
Medication Therapy Management
Prescription drug monitoring programs
Drug Utilization Review
Utilization Management:
- manage formularies
- prior authorizations
- step therapy
- quantity limits
Preferred & Exclusive Networks
Mail Order Pharmacy
Speciality Pharmacy

Question 12

Tiered Formulary

Answer 12

• design that financially rewards patient for using generic or preferred drugs by increase copayments of higher tier medications

Tier 1: preferred generic
Tier 2: non-preferred generic
Tier 3: preferred brand
Tier 4: non-preferred brand
Tier 5: preferred speciality
Tier 6: non-preferred speciality

Question 13

Percentage of Firms and Workers offering health benefits

Answer 13

the smaller the firm or business, the lower percentage of health benefits offered to workers

Question 14

Distribution of Health Plan Enrollment

Answer 14

Conventional plans have decreased over the years

HMO plans have decreased over the years

PPO/POS plans have stayed relatively consistent over the years

High-Deductible Heath plans have increased over the years

Question 15

Premier CDHP

Answer 15

highest premiums
lowest deductibles
lowest out-of-pocket maximum

Question 16

Standard CDHP

Answer 16

middle of the road premiums, deductible, and out-of-pocket maximum

Question 17

Limited CDHP

Answer 17

lowest premiums
highest deductible
highest out-of-pocket maximum

Question 18

All 3 CDHP contain

Answer 18

• same nationwide network of providers
• free preventative care with Tier 1 or Tier 2 provider
• free generic preventative medications
• HSA contributions (200$ single; 400$ family)

Question 19

Process of Purdue Health Plan

Answer 19

1. Pick CDHP
2. Patient pays full cost of services before deductible
   - can use HSA or Flexible Spending Account
3. After deductible is met, you and Purdue share costs (coinsurance)
4. After out-of-pocket maximum is met, you pay nothing for covered services for rest of year

Question 20

Cost of Health Plans with family

Answer 20

as you add children and spouses, your cost for health plan and premiums increase compared to single coverage

Question 21

How often are formulary changes made?

Answer 21

quarterly

Question 22

Average Annual Worker and Employer Contributions to Premiums

Answer 22

• both the employer & the workers are paying more in premiums as HC increases
• employers contribute more to premiums than workers

Question 23

Changes in Premiums, Inflation, and Earnings for Family Coverage from 2003-2023

Answer 23

• From 2003-2018, premium prices were increasing at a much higher rate than workers earnings and inflation
• 2018 to 2023, workers earnings have increased slightly more than premium prices
• DEDUCTIBLES ARE INCREASING AT MUCH HIGHER RATES THAN PREMIUMS, INFLATION, AND WORKERS EARNINGS

Question 24

Conceptual Model of flow of products

Answer 24

???

Question 25

AMCP

Answer 25

Academy of Managed Care Pharmacy

Question 26

Why is Population Health & Managed Care important to Pharmacists?

Answer 26

• population is living longer
• OVERUTILIZATION OF HEALTHCARE SERVICES
• Greater % of population eligible for Medicare/Medicaid
• impact of HC costs on federal budget
• new technologies increasing costs without evidence of better outcomes

Question 27

Health Insurers with PBMs

Answer 27

CVS Health –> Caremark PBM
- acquired Aetna

Cigna –> Express Scripts PBM

United Health –> Catamaran and Optum PBM