Exam 1 Flashcards
(180 cards)
1
Q
Describe the education training options available for pharmacists
A
Pharmacists
Residencies
Specialization licensure
Fellowships, graduate degrees
*Primarily practice in community pharmacies and hospitals
*More commonly practicing in non traditional pharmacy settings
(ambulatory care)
2
Q
Describe the education/training and scope of practice of various healthcare professions
A
Physicians
Worse in underserved areas (rural and inner city)
Primary care vs specialty
Nurses
Entry level RN and LPN require MD supervision
Advanced practice –> Nurse practitioner (DNP)
PAs
Requires physician supervision
Important and growing roles in both primary and specialty care
3
Q
Key components of pharmaceutical care
A
The responsible provision of drug therapy for the purpose of achieving outcomes that improve a patient’s quality of life
*Transition from product focus to service focus
*Activities involve (identifying actual or potential drug related problems, resolving actual problems, preventing potential problems)
4
Q
Key components of medication therapy management
A
Comprehensive approach to helping patients maximize the benefits from drug therapy
Core elements:
-Medication therapy review
-Personal medication record
-Medication-related action plan
-Intervention and/or referral
-Documentation and follow-up
*shift to MTM reflects collaborative approach to care
5
Q
Describe the education training options available for pharmacist techs
A
Training is not standardized
Techs can either be certified or registered (depending on the state)
6
Q
Pharmacist patient care services
A
Services provided by pharmacists are delivered in collaboration with other health care providers
*These services may be provided in addition to or distinct froms the direct dispensing of prescription meds
7
Q
pharmaceutical care
A
The responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patients quality of life
8
Q
Medication Therapy management
A
Comprehensive approach to helping patients maximize the benefits from drug therapy
*shift to MTM reflects collaborative approach to care
8
Q
Core elements of MTM
A
Medication therapy review
Personal Medication record
Medication related action plan
Intervention and or referral
Documentation and follow up
9
Q
Key elements of MMS
A
Patient centered approach to care
Assessment of medication appropriateness, effectiveness, safety and adherence
Collaborative approach to care
Focus on health outcomes
Expected to deliver MMA using pharmacists patient care process
9
Q
Medication Management Services
A
A spectrum of patient centered, pharmacist provided, collaborative services, that focus on medication appropriateness, effectiveness, safety and adherence with the goal of improving health outcomes
10
Q
PCCP
A
Provides consistent process/framework for pharmacists when delivering patient care services
Collect info
Assess info for problems
Come up with Plan
Implement plan
Monitor and Evaluate plan
11
Q
Barriers to patient care activities
A
Drug product focus
Services not visible to patients
Other health care professionals
Lack of payment
Logistical barriers
Pharmacy ignorance and inertia
12
Q
pharmacy provider status
A
Refers to formal recognition of pharmacists as health care providers by orgs that pay for healthcare
Does not mean prescriptive authority
13
Q
Med adherence
A
Promoting adherence is an essential pharmacist role in many health care settings
Non adherence is major problem
Due to costs
14
Q
How do professions and occupations differ?
A
Professions are occupations that have systematic theory and body of knowledge, professional authority and special privileges, community sanction and social utility, ethical codes and internal control, and professional culture and organizations
15
Q
Does health care constitute a special case of a profession?
A
Yes healthcare is a special case of profession because while providing an individualized and unstandardized service might be logical, providers sometimes fail to do this
16
Q
What are the primary similarities shared between pharmacy and the other healthcare professions?
A
Pharmacy and medicine both have a variety of specialties available
17
Q
What are the major differences between pharmacy and other healthcare professions?
A
Pharmacy is unique in that specialization is achieved after one is eligible to practice not before
18
Q
How would you explain to a patient the benefits of interdisciplinary care over multidisciplinary care?
A
Interdisciplinary care is a collaborative approach that involves multiple healthcare professionals working together to address a patient’s needs
Multidisciplinary care involves multiple healthcare professionals from DIFFERENT working together to address a patient’s needs
19
Q
For high-risk disease states pharmacists can reduce what
A
medication-related errors by collaborating with the team
20
Q
pharmacy-led interventions have been shown to improve
A
medication compliance in hospitalized, heart failure, and post-heart attack patients
21
Q
8 categories of drug-related problems that could arise and result in poorer health outcomes
A
untreated indications
improper drug selection
subtherapeutic dosage
failure to receive drugs
over dosage
adverse drug reactions
drug interactions
drug use without indications
22
Q
outcomes that improve a patient’s quality of life
A
-cure of a disease
-elimination or reduction of a patient’s symptomatology
-arresting or slowing of a disease process
-preventing a disease or symptomatology
23
covenantal relationship between pharmacist and patient
-identifying potential and actual drug-related problems
-resolving actual drug-related problems
-preventing potential drug-related problems
24
pharmaceutical care practice domains
1.Risk management
2.Patient advocacy
3.Disease management
4.Pharmaceutical care services marketing
5.Business management
25
medication synchronization
all of a patient's chronic medications are synchronized so that they are refilled one day each month
Improves patient outcomes but they also build efficiencies into a pharmacy's workflow by reducing walk-in traffic
26
The Pharmacists' Patient Care Process
1. Collection of necessary subjective and objection info about the patient
2. Assessment of the information collected
3. Development of an individualized patient-centered care plan
4. Implementation of the care plan
5. Monitor and evaluation of the care plan and modify the plan if need be
27
Pharmacotherapy consults
Services provided by pharmacists on referral from other health care providers or other pharmacists
28
Disease management
Involve coordinated healthcare interventions for diseases in which patients must assume some responsibility for their care
29
Pharmacogenomics
pharmacists play a role in the interpretation and application of a patients genetic info to optimize a patient's response to med therapy
30
Anticoagulation management
pharmacists provide services to patients who are taking oral blood thinning agents
31
Three essential components of healthcare systems
1.Cost
2.Access
3.Quality
32
Indemnity insurance
Insurance company reimburses subscribers not providers for a portion of their medical expenses
Now it refers to any health insurance program reimbursing on a fee for service basis with few cost controls
33
Healthcare system
A network of individuals and organizations that interact for the purpose of treating illnesses, preventing illnesses or maintaining health and financing care
34
General trends in health care
Diseases treated
Efficacy of care
Where care is provided
Who provides care
Payment for care
35
Historical evolution of the healthcare system
Prior to 20th century:
-Macro public issues
-Medical care was crude and unsophisticated
Early 20th century:
Role of the hospital: growth in importance as care centers
Rise in for-profit healthcare
Post WWII:
Failure of national health insurance reforms
-Creation of public programs
-Rise of private insurance
-Healthcare provided through "fee for service" system
Late 20th century
Managed care era
Strives to contain costs while delivering quality healthcare
Penalties for providing unnecessary care
21st century
Maturing managed care and controls
36
Self Pay (uninsured)
Pay as you go
37
Employer-sponsored insurance (private insurance)
Health insurance offered as a benefit of employment
-Part of premium paid by employer on employee's behalf
38
Individual Health insurance
Purchased by individual/family
Health insurance marketplace created under the affordable care act
39
Government/public sponsored insurance
Government is the payee
40
Healthcare expenditures
How much money is being spent on healthcare
Expenditures = Price x Quantity
41
Emerging trends
Growing focus on value and quality of care
Mergers and partnerships
42
Evolution of managed care
Goal: provide high value cost-effective care
Value = Outcomes/cost
43
Seven basic functions of the FDA?
Drugs cannot be sold or marketed until FDA approved
*Must be safe and effective
1.Approval of drugs on basis of purity, safety, and effectiveness
2.Regulation of labeling for prescription and OTC drugs
3. Regulation of prescription drug advertising
4. Regulation of manufacturing processes, recalls
5. Regulation of bioequivalence for generics and biosimilars
6. Monitoring of drugs after approval for problems
7. Monitoring of the safety of nation's blood supply
44
Steps for drug when going through development and approval
Can take many years and cost billions of dollars
1. Potential candidates (discovery)
2. Preclinical testing
3-5. Phase I, II, III clinical testing (Clinical testing)
6. FDA approval (approval)
7. Phase IV clinical trial (post clinical testing)
45
Phase I clinical trial
Must file Investigational New Drug (IND) application before
-How drug works, dosing, toxicities
-Small sample, healthy volunteers WITHOUT condition to be treated
46
Approval process for generic drugs
Abbreviated process
-Brand drug has already been proved to be safe and effective
Abbreviated NDA
-Submit proof of bioequivalence, bioavailability, PK and PD properties
*Very limited clinical testing
-Ensure the same or similar to reference product
47
Approval process for OTC
Over the counter switches
-NDA for new drug
OR
-Prescription to OTC application for drug with prior FDA approval
Implications for insurance coverage?
-Insurance less likely to cover prescription version
48
Biologics
-Large complex molecules created using BIOLOGICAL processes
-Often composed of proteins (antibodies)
-Expensive and difficult to produce (injections, infusions)
-NEARLY IMPOSSIBLE TO IDENTICALLY REPLICATE
49
Small molecule drugs
-small CHEMICALLY manufactured molecules
-relatively simple and cheap to produce
-refers to most "traditional" drugs (tablets, capsules)
-relatively simple to replicate
50
biosimiliar vs generic drugs
Biosimilars
Generally made from living sources
Complex process to produce
Very similar but not identical to original biologics (less expensive too)
Generics
Generally made from chemicals
Simple process to produce
Copy of brand drugs
Less expensive than brand name drugs
51
How do pharmaceutical manufacturers market their medications to prescribers and patients?
Marketing performed by drug manufacturers
Goals of marketing:
-Name/brand recognition
-Increase use of a particular company's drug
One method is detailing
-Target prescribers
-Go to them and educate them on the merits of the product
-Impact on prescribing behavior
-Drug representatives, journal ads, "swag" etc...
-Some info provided has been proven to be false or incomplete
-Excessive marketing (luxury trips, dinners etc.)
52
Issues with direct-to-consumer advertising
-Targets patients
Promotes drug directly to patients
-Purpose is to get patients to use OTC or prescription meds
Types: Drug vs Disease focused
Issues:
Patients don't have expertise to determine appropriate medical treatment and may contribute to higher costs of care
53
Phase II clinical trial
-Drug safety and effectiveness
-Small sample of patients WITH condition to be treated
54
Phase III clinical trial
-Drug safety and effectiveness via RCT
(compared to placebo and other drug)
-Large sample of patients with condition to be treated
55
New drug application (NDA)
Submitted before Phase IV clinical trial
-How drug works, how manufactured and marketed, labeling etc.
56
Phase IV clinical trial
"postmarking surveillance" -after drug approval
Monitor for potential adverse reactions, other problems
57
Summary of Generic Substitution
Generic (small molecule drugs)
-Can automatically substitute generic for brand version (unless specifically requested by prescriber or patient)
-Identical to brand version
Biosimilars
-Cannot be substituted without prescriber authorization
-Highly similar to brand version
Interchangeable biological product
-Can be substituted for the reference product without authorization
-Not all biosimilars are interchangeable biological products
-Nearly identical to brand version
58
Biosimilars and insurance
Biologic drugs and biosimilars typically fall under the specialty drug classification on a formulary
Biosimilars are intended to save money similar to generics so insurance plans treat them more like generics
59
Channel of distribution for Rx drugs
Manufacturers --> Wholesalers --> Pharmacies/pharmacists --> Patients / consumers / users
*Prescribers are an externality in the channel of distribution for prescription drugs
60
Brand name Manufacturers
-J and J, Merck etc..
-Research and development, drug discovery (main focus)
*Also called single source or patent protected drugs
*Role of patents is to create a unique product to a company and market it
*Play important roles in health care system
-Discover and produce innovative meds
-Info resources about new drugs
61
Generic Manufacturers
-Teva, Sandoz, Viatris, Sun Pharma etc...
*Also called off patent or multi-source drugs
*Limited research and development; (MAIN FOCUS IS EFFICIENT PRODUCTION)
*Price competitive markets
-Multiple competitors making same product
-Typically cheaper than brand drugs
62
Manufacturer trends
Increased use of generic drugs (account for large portion of prescription drugs, but small amount of drug spending)
Implications?
-Increase pressure to find new compounds
-More marketing, new indications, expand market, extend patents
-Stop selling branded version possibly?
63
Wholesalers
-McKesson, AmerisourceBergen, Cardinal Health
Purpose?
-Purchase, store and distribute drugs
-Technology solutions to improve efficiency
-Ensure integrity of drug distribution system?
**Drug pedigrees - identify each prior sale of the drug
64
Pharmacies
Many types
-Institutional (in patient)
-Community pharmacies
-Mail-order
-Specialty pharmacies
65
Community pharmacy trends
Steady growth of community pharmacies
-Growth in proportion of corporate owned chain pharmacies
-Location
*Many independent pharmacies in rural areas
66
Mail order pharmacies
Mail order prescriptions have increased
-Areas of debate
*Money away from community pharmacies
*Safety/quality of care
*More efficient/cost effective
67
Prescribers (Providers)
MDs, NPs, PAs, and PharmD in some settings
Decide what drugs will be used by patients
*"Directed demand"
*Don't pay, possess, or dispense drugs
Act as agents for patients
68
Non-Distribution pathway (Insurance)
1. Funders (employers/Government)
2. Payers / Insurers
-PBMs work for payers and get reimbursement (point of corruption?)
3. Pharmacies or Pharmacists
4. Patients, Consumers, Users
69
Pharmaceutical Benefit Managers (PBMs)
-CVS/Caremark, Express Scripts, OptumRx, Navitus
-Administer drug plan on behalf of INSURERS, EMPLOYERS
*Claims processing
*Establish controls in drug plans
-Buy prescription services from pharmacies
*Establish reimbursement levels to pharmacies for drugs
*Determine pharmacy networks
-Most PBMs own a mail order/specialty pharmacy
-Negotiate Rebates with Manufacturers
70
PBM trends
Large growth in Third Party coverage of prescriptions
Concentration of market power in PBM industry resulting in tension with pharmacies
-Reduction in reimbursement levels to pharmacies
-Narrow or tiered pharmacy networks
-Forced or incentivized use of PBM owned mail order pharmacy
71
Issues faced by PBMs
-Rising drug costs (aging of pop, cost control measures)
-Vertical integration with medical services
*Mergers between PBMs and health insurance plans, health systems
*Concerns about lack of cost savings, restricted patient access, and anticompetitive behaviors
72
Specialty drugs
Often biologic agents that are difficult to produce
-Require special handling, storage or delivery
-Require clinical monitoring and patient education
-Significantly more expensive than traditional medications
Specialty pharmacies are a rapidly growing sector
73
Uninsured changing trends
Uninsured patients face significant barriers to care
-Changing trends in uninsured rates
*Steady decline to 2016 (Affordable Care Act), then brief increase (COVID-19), now declining again
Still millions uninsured
Important Racial Disparities in insurance coverage
74
Organization of the Third Party Prescription Industry
-Providers gives care/drugs to patient, employee, and beneficiaries
-Patients/others pay premiums to employers or Government (or insurer directly) who pay premiums to insurer
-Insurers reimburse providers and the PBMs work for them
75
Cost sharing/Out of pocket cost
Copayments - set payment amount
Coinsurance - percentage of drug cost
76
Desired outcomes from insurance
Patients/users: Get health stuff covered
Providers: Consistent patient load, and reimbursement, freedom from restrictive policies
Employers: Healthy and satisfied employees, high quality of care and low cost
Insurers/payers: To charge the patients and providers as much as possible and make a profit
77
Goal of insurance and types of risk
reduce unanticipated risk
Pure risk --> Fire
*Only risk that is insurable
Speculative Risk --> Gambling
78
A Pure risk is insurable if
1. Calculable probability of event
2. Relatively rare event and cannot ID individual who will experience event
3. Accidental loss
4. Result is substantial loss
5. Loss is measurable
6. Individual has insurable interest
79
Why do health insurance plans cover prescription drugs despite their incompatibility with some risk management principles?
Prescription drugs in general are not an insurable event
*Drugs are not a substantial loss to the insurer
*Prevents hospitalization/worsening of disease in patient
80
Risk management problems for insurers
Law of large numbers allows accurate prediction of risk/losses MOST times
-Adverse selection
-Moral Hazard
-Catastrophic hazard and opportunities for significant loss
-Supplier induced demand
81
Moral Hazard
Insurance coverage causes people to overuse health healthcare
*Decreased cost so increased use
Potential solutions:
-Cost controls (limit/exclude low value drugs)
-Vary cost sharing (deductibles, copayments, coinsurance)
82
Adverse selection
People purchase insurance only when they know they need it
-"Only covering those who will use care"
Potential solutions:
-Mandatory coverage
-Elimination period
-Self insured plans
83
Provider induced demand
Physicians create demand for their services
Potential solutions:
-Move from fee for service to other payment structure
84
Catastrophic hazard
Catastrophic, widespread events that would exceed company's ability to pay
Potential solutions:
-Policies generally exclude catastrophic losses caused by natural disaster or war
To limit other significant losses:
-Exclude certain services
*Elective treatments
*Not medically necessary drugs
-Loss maximums
*Insurance companies may still cover a service but limit the amount they will pay
85
Managed care
Movement away from strict payment for services to value management of health care services
Value = cost/outcomes
Cost = unit price * volume
*provides cost effective care with finite resources
86
managed care pharmacy
The practice of applying evidence based medicine to support the appropriate use of medications to enhance patient and population health outcomes while optimizing health care resources
87
Features of a managed care approach
provided by managed care organizations
MCO assumes financial risk for expenditures
1973 Health Maintenance Organization Act: Required employers to provide HMO option
2010 Affordable Care Act: Requires large employers (>50 employees) to provide health coverage
88
Key roles of managed care organizations
1. Insurance (taking risk)
-Traditional role of protecting customers against unexpected or catastrophic financial losses
2. Negotiate costs of health services
-MCOs or their subcontracted vendors use their market leverage to negotiate favorable rates with providers of care
3. Managing care
-Benefit design
-Utilization management
-Leveraging data and provider relationships to identify and manage high risk patients
89
HMO (Health Management Org)
-CLOSED network: Coverage outside network based on medical need only
-Low cost/high quality option for employees with in network providers or who don't use many health care services
89
Customers of MCOs
1. Employers
-Purchasing health insurance on behalf of employees
-Employer and employee split premium payments
2. Individuals
-MCOs cannot underwrite based on prior medical history or gender
-Lower income individuals subsidized by Gov
3. Government
-Medicare/Medicaid
90
POS (point of service)
-OPTION to go out of network for higher cost share
-Somewhat higher cost, less control than HMO, lower cost than PPO
91
PPO (preferred provider organization)
Very broad usually nationwide network
Often offered for employees who are not located within the geography of the HMO network
92
Approaches to payment for health care services
Fee-For-Service (FFS)
-Pay per click payment for EVERY covered service provided
-Based on 5 of charge or other pricing benchmark
-Rewards increased intensity of services
Capitation
-Per member per month prospective payment from MCO to provider
-Shifts risk from MCO to provider
-Rewards efficient use of providers and services
-Generally only in HMO
93
Quality inn managed care
Growing emphasis on ensuring quality of care
Assessed using 3 domains
-structure, process, outcomes
94
Purpose and role of accreditation in ensuring quality
National Committee for Quality Assurance
Voluntary MCO accreditation
Administrative standards (protects patient), process standards and outcomes
95
Implications of provider risk sharing
Financial Risk: Providers can experience financial loss when participating in risk sharing
96
Medical benefit
Meds typically administered in healthcare setting
Reimbursement:
-Can be reimbursed as part of PROSPECTIVE capitation payments or RETROSPECTIVELY with FFS
-Claim not submitted until after drug adminsitered
97
Pharmacy benefit
Meds dispensed at pharmacy and self administered
Reimbursement:
-Pharmacies paid after product is dispensed
-Claim adjudicated before Rx dispensed
98
Role of PBMs
-Real time administration of complex drug benefits
-Offer expertise, market leverage and economies of scale
-Drug benefits adminstered separate from other health benefits
99
Services provided by PBMs
Claims adjudication (processing claims)
-Online electronic claims submission system process claims
-Notify pharmacy of formulary status, limits, payment
Drug utilization review
-Ensure appropriate, safe, effective drug use.
-Retrospective (after the fact) vs prospective (prior to )
Rebate negotiations
Formulary management
Pharmacy network development
-Expand network to different areas (retail, mail order, specialty, home infusion) or location expansion
100
Medical underwriting
A process used by insurance companies to try to figure out your health status when you're applying for health insurance coverage to determine whether to offer you coverage
101
Gatekeeper
primary care physicians who serve as the initial point of contact for patients seeking healthcare services
102
Third party payer
organizations that pay for medical expenses on behalf of a patient, or the individual receiving the service
103
How do PBMs control prescription drug costs and utilization?
Drug Formulary
-Prior Authorization/step therapy
-Generic substitution
-Provider education
Patient cost sharing
Utilization limits
Patient education
104
Drug Formulary
List of drugs approved for use
-balance cost v clinical value
-identities preferred vs nonpreferred agents
Types
Open (all drugs covered) vs closed formularies
-Tiered formularies (specialty drugs, excluded drugs)
105
How are drug formularies structured?
1. The size of manufacturer discounts and rebates
(offer bigger discounts/rebates to get better spot)
2. Patient cost sharing amounts
-formulary tiers used to group drugs based on cost
-provides financial incentives to use cheaper drugs
106
Prior authorization
Series of steps prescribers can complete to request drug coverage for a noncovered medication for their patient
Purpose:
Ensure drug use is appropriate, evidence based, and cost effective
Drugs that are targeted?
Drugs for rare conditions, specialty medications, drug classes with brand and generic options
107
Step therapy
Variation on drug formularies and prior authorizations
First requires a patient to try a more cost effective med, that has been shown to be beneficial to most patients
If not effective patient tries more expensive agent
108
Generic substitution
Substitute generic drugs for brand drugs
Mandatory generic substitution
-patient or prescriber may request brand drug (might not be approved makes pharmacists job harder)
PBMs use incentives to use generics
-lower patient copays
-higher pharmacy reimbursement
109
Provider education
Physician profiling
-Comparing practice patterns of providers on cost and quality
Counter detailing
-Health plans and PBMs monitor prescribing patterns and identify inappropriate prescribing
110
Patient cost sharing
Requires patients to share in cost of medication
Tiered cost sharing to promote use of cheaper agents
Types:
Copayments - set payment amount
Coinsurance - percentage of drug cost
Deductible - amount paid before coverage kicks in
Out of pocket limits - caps patient out of pocket costs
111
Utilization limits
Purpose: To minimize fraud and medication waste
Quantity limits:
-limit on number of pills or days supply
-30 day vs 90 day supply
Refill too soon:
-Vacation overrides/lost meds
Quantity minimums
-90 day requirements for maintenance meds for chronic conditions
112
Patient education
Goal: produce voluntary change in patient behavior
113
Patient cost sharing emerging trends
Increasing out of pocket costs
Seasonal trends in prescription drug spending
Value based insurance design
114
History of health insurance
Prior to 20th century:
-Disability insurance
-Protect from loss of income due to illness
-Targeted health demand not supply
Early 20th century:
-Insurance plan reimburses patient
-Insurance plan for physician services
-Organized physicians into a large group practice
Mid 20th century:
-Gradual shift from indemnity to service benefit insurance
-Creation of comprehensive insurance plan
115
Indemnity insurance
Approach:
-Patient pays full price to provider, submit receipts to insurance for reimbursement
-Original approach
Problems:
-Few cost controls
-Cumbersome for patient and insurance
*not really used today
116
Service benefit insurance
Most common process for reimbursing health care
Provider bills insurer, directly paid by insurance
Cost savings
*Standardization and automation of claims processing and payment
*Cost/utilization controls
117
History of prescription drug insurance
Outpatient drug insurance uncommon until 1970s
Slow growth in adoption
1. Lower cost = lower priority
2. Large number of small claims
3. Legal barriers
Creation of precursors to PBMs led to more rapid growth
118
Current trends in health insurance
-Affordability concerns for employers, employees
-Slow decline in private insurance
-Impact of pandemic?
Increase of uninsured Americans because of loss of employer health insurance
119
Health care affordability trends
Insurance coverage a focus of health reform
-Decline in uninsured rates and rise in underinsured
Growing concerns about health care affordability
Rates are significantly higher among uninsured, minority and low income
120
Uninsured vs underinsured
Uninsured:
lack of coverage for all needed care, high out of pocket costs, etc.
Underinsured:
Have insurance coverage but not enough to cover health care needs.
121
How have the purpose and goals of health insurance changed over time?
-Shift from protecting providers to protecting patients
-Patients with most need for care shifted to public sector
-Rise of managed care
*Cost and utilization controls
*All incorporate managed care principles to some extent
122
Eligibility requirements of the Medicare program
65 and older
Under 65 with
*Permanent disability
*End stage renal disease
*ALS
Must meet other detailed requirements or pay extra premium (pay more if under 65 with special conditions)
123
Medicare program structure
Part A -> Hospital insurance
Part B -> Supplemental Medical Insurance
Part C -> Medicare Advantage
Part D -> Prescription drug benefit
124
Benefits under Medicare part A
It is a mandatory benefit so no premium
Covers "Hospital Insurance"
-Inpatient care
-Skilled nursing facility
*Short term (acute) care only
*Long term care NOT covered
-Home health care
-Hospice care
-EMS
125
Benefit period
Every time you are admitted to hospital or skilled nursing facility
*starts the day you are admitted
*ends when you're not a patient
126
Medicare population description
Mostly above 65 (88%) - less expensive to cover
But under 65 is smaller (12%) but WAY more expensive to cover (multiple chronic conditions)
127
Cost sharing in Medicare Part A
When admitted to a hospital or skilled nursing facility:
-Have to repay the deductible for each benefit period
-The cost sharing changes over the duration of the benefit period
Exception: No cost sharing for home health care, and there is minimal coinsurance for hospice care
128
How is part A structured?
*Emergency coverage in all hospitals (whether they are in Medicare or not)
-Includes some hospitals in Canada & Mexico
*In general doesn't cover care outside US
Coverage limits
*Only covers basic services
Pay a one time deductible days 1-60
Pay a daily copayment days 60-90
No coverage day 90 and on
129
Medicare part B structure
OPTIONAL benefit so income based monthly premium
SUPPLEMENTARY MEDICAL INSURANCE
EX: part B covers everything that part A doesn't such as surgeries
130
What does Medicare part B cover
Inpatient/outpatient physician services
Preventative services, diagnostic services
Limited drug coverage
*drugs administered by a provider during a hospital visit
*immunosuppressing drugs following a transplant
-Diabetic test strips
-Durable medical equipment
*Fee-for-service payment
131
Part B cost sharing
Pay an ANNUAL deductible
Coinsurance is 20%
Assignment charges:
If the provider accepts the patient the provider charges what Medicare will pay and the patient pays 20% of the service (approved charge)
If the provider doesn't accept the patient the provider will charge more than what Medicare will pay and the patient will pay the 20% of the service plus the difference between the provider and Medicare amounts (Balance billing)
132
Services NOT covered by Medicare part A and B
-Long term care
-Routine physical exams
-Routine vision and hearing tests
-Hearing aids
-Routine dental care
-Homemaker services
-Healthcare outside US (only Mexico and Canada)
-NO prescription drugs --> covered by part D
-Pharmacist clinical services
133
Pharmacist provider status movement
-Pharmacists are not recognized as "providers" in Medicare (Goes from state to state)
*No reimbursement for patient care services provided by a pharmacist
Bills introduced to change this
-Pharmacy and Medically underserved areas enhancement act. S 1491
*Only an issue in the Medicare part B program and medically underserved areas
134
Provider status for pharmacists benefits
Allows pharmacists to charge for services in underserved areas and have significant cost savings for the US
135
Provider status for pharmacists implications
WOULD NOT apply to all Medicare Part B beneficiaries or grant pharmacists new practice authorities
136
Pharmacist services in Medicare
During COVID pharmacists had temporary authorization to provide care and receive reimbursement for pandemic related services for Medicare part B
*New bipartisan legislation proposed to make the changes permanent
Much more limited in scope than provider status
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Medicare Part C
-Optional benefit
-Managed care plans (medicare advantage)
-Administered by private companies
*HMO or PPO structure
*Prepaid care
-Increasing enrollment trends
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Benefits of Medicare part C?
Combines A and B coverage
-May result in reduced premiums
-Plan may cover more services
-Plan may cover services to a greater extent
*TYPICALLY INCLUDES PART D COVERAGE
Trading access for lower costs, more benefits
Each plan is unique
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Medicare Part D
outpatient prescription drug coverage
(additional monthly premium)
*Voluntary benefit
-Subsidies available for low income beneficiaries
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Creditable coverage
Coverage equivalent to Part D coverage
*If have none must pay premium penalty if decide to enroll in Part D later
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Part D coverage
PDP - stand alone drug coverage
(Prescription drug plan)
MA-PD - Part D coverage through a part C plan
(Medicare Advantage Prescription Drug)
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Medicare part D coverage gap
Known as doughnut hole
Purpose is to make more money for Pharma
Problems:
-Can't afford drugs
-Stop taking drugs, skip doses
-Health problems, hospitalizations
ACA --> meant to close coverage gap
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Medicare Part D structure
Standard benefit vs actual benefit
-Can organize benefit however they want
(Must be at least as generous as standard benefit (equivalent))
Required to cover most prescription drugs
*Have to pay penalty if no part D
Use formularies and other cost control mechanisms
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Medicare drug price negotiations
Current policy: Medicare cannot negotiate with drug manufacturers for reduced costs in part B or part D
*Private companies can negotiate part D costs
New policy: Inflation reduction act implements Medicare price negotiations for part B and D
*Private companies can still negotiate discounts for all nonrestricted and excluded drugs
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Pharmacists role in Part D
Dispensing meds to part D beneficiaries
Plan selection and enrollment
Explaining benefits
Immunizations/vaccinations
*Required to cover vaccines not already included in part B
-Shingles, Hepatitis A, Tdap, etc.
Medication Therapy Management (MTM) services
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Standard benefit Medicare part D
4 tiers
1. Deductible - patient pays deductible and premium
2. Initial coverage phase - Patient pays 75% Medicare pays 25%
3. Coverage gap phase - Patient pays 100%
4. Catastrophic coverage - Medicare pays 95% Patient pays a small portion (~5%)
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Current standard benefit Medicare part D
still 4 phases
1. Deductible
2. Initial coverage phase
3. Coverage gap phase
4. Catastrophic coverage
*Changes
They are removing the coverage gap phase
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Part D MTM eligibility criteria
1.Have multiple chronic diseases
2. Take multiple part D drugs
3. Likely to incur high spending for covered Part D drugs
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MTM required services
1. Interventions for beneficiaries and prescribers
2. Annual Comprehensive Medication Review (CMR)
3. Quarterly targeted medication reviews (w/ follow up if needed)
4. Information on safe disposal of medications
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Medigap
Private insurance plans that cover many of the charges not covered by Medicare
Fills in coverage gaps in Medicare
*Medicare supplement insurance
-Part C beneficiaries not eligible
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Issues with Medicare program
-Insufficient funding for Medicare part A
*Revenue from taxes < health care expenses
-Affordability of premiums
*Increase on limited income
*Primarily parts B, C, D
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Solutions for Medicare problems?
Raise age for Medicare eligibility
Reduce health care costs
Increase tax rate
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Goals of Medicare's quality initiatives
Tying quality of care to reimbursement in an effort to reduce unnecessary spending
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Medicare hospital readmissions reduction program
Financial penalties for unnecessary 30 day hospital admission
Incentive for hospitals to ensure patients are discharged appropriately
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Medicare star ratings program
-Nursing homes, Part C and D plans
-Ties to financial and marketing incentives/bonuses
-Rated on customer service, member experience/satisfaction
-Pharmacy: med adherence, annual CMR provided
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Medicare program structure
Part A
-Coverage provided by Medicare program directly
-Funded by payroll taxes
Part B
-Coverage by Medicare program directly
-Funded by premiums
Part C/D
-Administered by private companies on behalf of Medicare program
-Funded by premiums
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Medicaid Structure
Every state Medicaid program is different and administered by CMS which also does Medicare
-Jointly funded by federal and state governments
-Broad guidelines established by feds
-Optional program (states don't have to participate but all do)
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Who is eligible for Medicaid
1. Mandated categorically needy (required)
-Welfare recipients, elderly/blind/disabled, low income seniors
2. Optionally categorically needy (optional)
-Primarily low income children, pregnant women that don't meet mandatory coverage
3. Medically needy (optional)
-Elderly, blind, disabled, children with high out of pocket expenses
***Income is not the only criteria for Medicaid
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CHIP (Children's Health Insurance Program) role
Cover's children that are ineligible for Medicaid
*Income/financial resources too high for Medicaid
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CHIP structure
Similar structure to Medicaid (joint federal/state program)
Covers broad range of services
*Preventative care, Immunizations, doctor visits, emergency care, prescription drugs, etc.
OOP vary by state
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Characteristics of populations covered by Medicaid
*mostly children with income < federal poverty level
*Affects minority and nonelderly people with disabilities groups primarily
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Medicaid role in the US health care system
Support for Health Care system and safety net
Gives state capacity to address health challenges
Lots of coverage for Americans
Primary role in financing long term care
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Mandatory services under Medicaid
-Inpatient and outpatient hospital services
-Lab & XRAY services
-Nursing home and home health care
-Family planning, pregnancy related services
-Midwife, physician, nurse practitioner services
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Optional services under Medicaid?
-Podiatry
-Optometry
-Prescription drugs
-Dental
-Hospice
-Clinic services
Covered services may vary by eligibility
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General Medicaid program requirements:
Covered services must be the same throughout the state
Freedom of choice: Medicaid recipients must be allowed to obtain services from any PARTICIPATING provider
Coverage must be same for mandatory and optional eligibility categories
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Medicaid cost sharing
-States have broad discretion
-Many states require cost sharing
-BUT COST SHARING CANNOT BE SERIOUS BARRIER TO RECEIVING SERVICES
-Nursing home patients contribute most of their income to pay for care
-Cost sharing prohibited for some services
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Medicaid cost controls
Cost and utilization controls target patients, hospitals, physicians, pharmacies, manufacturers
*Use prior authorizations, preferred/non-preferred drugs, discounted reimbursement, drug rebates
Preferred drug lists (PDLs) = Medicaid formulary
Medicaid managed care plans
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Provider payment for Medicaid services
Medicaid programs directly pay participating providers using FFS (traditional)
-Use prepayment (capitation)
-Provider participation is optional (if they accept the assignment they need to take Medicaid's payment)
**Reimbursement is heavily discounted
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Issues faced by Medicaid/CHIP
Budget cut, growing health care costs, accountability
Difficult pop covered
Low provider reimbursement '
Federal state coordination
*Medicaid expansion with ACA
Covid 19 pandemic (more enrollment, policies ended recently)
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How is the US Gov involved in healthcare?
Legislation: Establishing health care laws on a state and national level
Administrative regulation: Regulatory policy to include oversight and management
Reimbursement: Establishing reimbursement rates and mandated rebates
Direct care: Direct patient care and health care delivery
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Current Government Involvement
COVID- Testing, vaccine planning, mask mandates / recommendations, funding and reimbursement
Legislative initiatives- Inflation Reduction Act, PBM reform, drug price and transparency, Medicaid expansion, WI act 98, federal provider status.
*All significant transformation of health care involves the federal and/or state government
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VA
Closed health system
Single integrated health system
-VA is the provider, PBM, payer, and the pharmacy
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What makes the VA unique?
VA has a national drug formulary (different tiers)
*If the medication is used to treat a service related condition, then the veteran doesn't pay for the medication.
Reliance on mail order pharmacies
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Delivery of care in VA
Patients are assigned a Patient Aligned Care Team (PACT)
-PCP, Pharmacist, social worker, nurse and support staff
*Pharmacists play an integral role in care delivery
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How are federal pharmacists unique?
May be licensed in any US state or territory
Ability to transfer to other federal facilities with preferred hiring
Follow federal not state law
Offer clinical or administrative roles
May be uniformed or civilian pharmacist
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VA vs Tricare
VA - Serves veterans, and medical retirees (no family members)
Healthcare system type - Primarily closed
Relationship with ext providers: Limited access to community providers when access standards aren't met
Pharmacy Residency match - YES
Tricare - Active duty service members and families, retired military
Healthcare system type - Direct care or purchased care
Relationship with ext providers - 2/3 of medical care provided by community based providers
Pharmacy residency match - NO
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Additional Federal Health Care systems
Indian Health Service, Federal Bureau of Prisons
