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Final Flashcards

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1
Q

What is the 3 tier system of medication distribution

A

manufacturers
wholesalers
retail pharmacies

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2
Q

What are the 4 sections of medication distribution

A

manufacturers
research and developement services
management of med use
pharmacy wholesalers
retail pharmacies dispense to pt

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3
Q

What are biopharmaceutical industry companies goal

A

develop, manufacture, market, distribute drugs

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4
Q

What does the FDA oversee

A

drug safety and efficacy
marketing and promotion
product communications and labeling

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5
Q

What are me-too drugs

A

drug entering into a drug class which brings no new health benefit to market

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6
Q

What are PhRMA issues

A

research/product selection
direct to consumer advertising
pay to prescribe

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7
Q

What do PBMs manage in outpatient medication for beneficiaries

A

establish formulary for insurance plan
(purchase drugs, negotiate prices)
manage use of med by pt (star rating)
charge DIR fees to retail pharmacies

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8
Q

What are wholesalers

A

purchase, inventory and sell a manufacturers complete pharmaceutical product line

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9
Q

What are the 4 wholesaler trends

A

improve generic marketplace
evolution/growth of specialty pharmacy
grow rx demand and customer consolidation
era of global drug distribution

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10
Q

How are wholesalers benefitting to clinents (pharmacies)

A

price advising
educational resources
marketing resources
software resources
manufacturer relationships

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11
Q

What is buying power (group purchasing organizations)

A

small/regional chains and independents align with other pharmacies to form purchasing groups
incentive to work together to increase business

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12
Q

Pharmacy service functions can be completed by an outside vendor or entirely carved out because of what 3 things

A

Pharmacy is an easily defined benefit
Pharmacy has a defined pt pop
High or rising costs

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13
Q

Key pbm activities

A

Manages reimbursement
Consultation for benefit design
Creates retail markets
Rebate programs
Specialty mail
P&T committees
Capabilities reporting

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14
Q

What are the parties involved before a prescription drug is reimbursed and finally reaches the patient

A

Drug -> manufacturers -> wholesaler
Rx -> prescriber -> payer
Both go to pharmacy and then pt

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15
Q

AWP (average wholesale price)

A

Most common used in drug pricing
Third parties publish this price for public knowledge

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16
Q

WAC (wholesale acquisition cost)

A

Most common for pharmacy purchasing of drugs
Published by manufacturer for sale via wholesaler
Pricing does not exist for all drugs

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17
Q

GPO (group purchasing organizations)

A

Group purchasing organization created to leverage the purchasing power of a group of businesses to obtain discounts from vendors based on the collective buying power of the GPO members

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18
Q

NADAC (national average drug acquisition cost)

A

Average wholesale price calculated by what is paid by retail pharmacies for prescription and OTC
Data generated by monthly surveys and updated weekly
Utilized by CMS

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19
Q

AMP (average manufacturer price)

A

Part of OBRA
Average price paid to the manufacturer for the drug in the US by wholesalers for drugs distributed to the retail pharmacy class of trade excluding customary prompt pay discounts extended to wholesalers

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20
Q

Best price

A

Brand name drugs
Lowest price available from the manufacturer during the rebate period to any entity in the US in any pricing structure

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21
Q

AWP roll back

A

Brand drugs AWP has correlation to WAC
The listed AWP for most brand drugs was “rolled back” 5%
FDB no longer publishes the AWP price

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22
Q
A
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23
Q

PSAO (pharmacy services admin organizations)

A

Basically reimbursement GPO
Help negotiate the highest reimbursement for the individual pharmacies

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24
Q

MAC (maximum allowable cost)

A

Applies to multi source generic drugs
Payer or PBM determined price
Price allows payers to pay the same price for a drug

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25
Cost savings tools
Formulary Generic substitution Drug utilization review Quantity limits Prior auth option Step therapy
26
Admin fees
Fee charges for every claim processed
27
Spread pricing
What PBM charges plan sponsor is different than what pharmacy is reimbursed
28
MAC list
Proprietary list of meds and max reimbursement price that PBM uses
29
Rebates
Portion or all can be passed to plan sponsor or PBM can keep percentage
30
Drug pricing is variable based on the type of what transactions
Wholesaler to pharmacy Pharmacy to third party payer Pharmacy to Medicaid
31
Who dictates value based care
NCQA, CMS, AHRQ, IHI
32
What is NCQA
develops performance measures known as the healthcare effectiveness data and information set (HEDIS)
33
What are the 3 programs under CMS
medicare shared savings programs (MSSP) bundled payments for care improvement (BPCI) quality payment program (QPP) - includes MIPS/APM
34
What is ARHQ
producing evidence to support the development of quality metrics that improve healthcare delivery
35
What is IHI
develops and promotes quality improvement strategies and collaborates with other orgs to create quality metrics
36
IHI quintuple aim
pt experience pop health reducing cost care team well-being health equity
37
Improving population health goal
enhance the health of populations by focusing on preventive care, chronic disease management, and addressing social determinants of health
38
Improving population health key focus
reduce health disparities, improving access to care, implementing community based interventions
39
Improving the patient experience of care goal
improve the quality of care from the patient's perspective, making healthcare more patient-centered
40
Improving the patient experience of care key focus
enhance communication, pt satisfaction, and engagement. It emphasizes ensuring that care is respectful of and responsive to individual patient preferences, needs, and values
41
Reducing per capita healthcare costs goal
control the rising cost of healthcare by improving efficiency and reducing unnecessary spending, all while maintaining or improving the quality of care
42
Reducing per capita healthcare costs key focus
optimizing resource use, reducing waste, and managing healthcare costs across the system (encourage value-based care models that reward outcomes rather than volume)
43
Improving the work life and well being of healthcare providers goal
to prevent burnout, increase job satisfaction, and enhance the overall quality of care provided
44
Improving the work life and well being of healthcare providers key focus
adress burnout, promote work-life balance, create supportive network environments
45
Achieving high equity goal
ensure that all individuals have access to high-quality healthcare
46
Achieving high equity key focus
Reduce healthcare disparities, improve access to care for underserved and vulnerable populations
47
PCMH (patient centered medical homes)
improve primary care delivery by making it more patient-centered, accessible, and coordinated emphasizes continuity strong focus on preventative care and coordinated care across providers
48
PCMH key features
pt centered care comprehensive care coordinated care access to care quality and safety team-based care
49
ACO (accountable care organizations)
groups of healthcare providers who work together for pt goal to get the right care at the right time while avoiding unnecessary duplication of services
50
ACO key features
coordinated care shared saving model pt centered approach quality metrics risk sharing pop health management
51
What are the types of ACOs
medicare shared savings programs (MSSP) commercial ACO
52
Bundled payments
provide a single payment for all services related to treatment or condition encourages providers to collaborate and manage cost effectively to avoid unnecessary tests or procedures
53
Bundled payments key features
improved care coordination cost savings better outcomes incentive for quality over volume
54
Value-based payment model
providers are rewarded for achieving specific health outcomes rather than volume of services provided -hospital readmissions, improved management of chronic conditions
55
Capitation
providers are paid a set amount per patient per period, regardless of how much care the pt requires
56
Value based insurance
impact ratings compared to other pharmacies/provider clinics increase reimbursement/get incentives for higher performance higher performing clinics and pharmacies may get preferred status or preferenced with patients
57
What is Medicare star ratings
part D prescription drug plans rating go from 1 to 5 (highest) rating help pt compare plans and pharmacy services based on specific quality indicators
58
EQUIPP
performance information management tool that provides standardized benchmarked performance info needed to shape strategies and guide med-related performance efforts
59
DIR fees
direct and indirect remuneration fees charged to pharmacies by PBMs/health insurance companies these fees reduce the amount of money pharmacies actually receive started as only part D, but may also be commercial
60
Tracking DIR fees
there is no current way to track them
61
What is tiering
a pharmacy benefit design that financially rewards patient for using generic and preferred drugs (pay more for brands)
62
What structure is not applicable to plans where there is zero cost share to members for medications
tier (ex: many medicaid plans)
63
What is tier 0-4
0: ACA preventive medications 1: generic 2: preferred brand 3: non-preferred brand 4: specialty drugs
64
ACA preventive medications
required by regulation to be covered at zero cost to members for most plan types -applied to all private plans -made by USPSTF, ACIP, HRSA, IOM
65
Specialty medications
for meds such as multiple sclerosis, hemophilia, hepatitis, and rheumatoid arthritis -infused/injected meds -unique storage -additional educations (REMS) -usually not at retail pharmacies -high cost
66
Member cost share
the amount of the prescription the member pays
67
Coinsurance
member pays a % of the total ingredient cost
68
Copay
member pays a flat fee for each prescription -fee dependent on med tier
69
Deductible based benefits
designed as part of HDHP deductible is applicable to medical and pharmacy spend
70
Mandatory mail
members can receive an initial dose at a retail pharmacy, but member will be penalized if they do not switch to mail after the first few fills
71
Preferred pharmacy networks
PBMs will contract specific pharmacies to be "preferred" in their network, allowing lower copays or a separate copay structure if the member uses a particular pharmacies
72
Specialty Benefits
all specialty drugs must go through a specific specialty pharmacy providers -have significantly higher member cost share
73
Excluded drug classes
OTC, fertility drugs, erectile dysfunction drugs, growth hormone, wt loss drugs, compounds
74
Formulary
a formulary is a list of drugs that are covered by insurance and details of how those drugs are covered
75
Types of formularies
open: all drugs covered but some may have restrictions closed: smaller list of drugs, new drugs are not added until reviewed and approved by P&T
76
What 3 decisions on all the following are proposed and presented to the P&T committee
formulary vs non-formulary meds tier placements of meds utilization management tools
77
Utilization management tools (aka:cost containment strategies (CCS))
implemented to promote: prior auth, step therapy, quantity limits
78
Prior Authorizations
requires review and approval prior to being covered can incorporate trials of other drugs specific criteria approved P&T and used by reviewers denials require pharmacist of physician reviews
79
Step therapy
can be set up with a PBM to have a computer system look for required drugs to use prior to coverage of requested agents
80
Quantity Limits
allows a limit to be placed on meds to ensure proper usage of dosage forms and can implement management of max daily dosages
81
Factors influencing formulary status
decision to add a drug to formulary based on efficacy, safety, cost drug class/disease state review novel agent or me too drug drug orally admin or inj
82
What to look at if decision is made to add the drug to the formulary
what tier should drug be placed on is it placed in "preferred" position need to add any utilization managements will rebates be impacted by UM
83
Implementation of formulary status
communications (providers/members) PBM coding changes posting formulary lists/pdls posting what is required to submit for PA
84
Tips for point of sale
read rejection reasons suggestions to member on next steps initiate PA process or provider outreach discount programs
85
Paramount lines of business (LOB)
commercial/exchange medicaid terminated w/ ohio dept of medicaid in 2022 medicare
86
What do PBMs do for plan sponsors/health plans/payers
pharmacy network contracting (retail, mail, LTC, HI, specialty) formulary management administer the pharmacy benefit and plan design pharma rebate contracting
87
Formulary and benefit admin
MA-PD plans and employer PDP utilization management (UM) programs PA, ST, QL) drug utilization review (DUR)
88
Clinical programs for paramount PBM
coverage determinations medicare star rating MTM gaps in care
89
Subcontracting for paramount PBM
retail network manufacturer rebates
90
Operational support for paramount PBM
prescription drug events medicare plan finder pricing files EOBs part D program audit medicare compliance
91
Major sections of a PBM contract
parties to the agreement term (3 yrs) scope of service compliance w/ rules, regulations, law financial exhibit reporting performance guarantees audit terms
92
Traditional or "lock in" or "spread" pricing
PBM pays pharmacy for a submitted brand or generic drug claim and that is different, often lower than the price pad by the plan sponsor to the PBM
93
Pass-through pricing
what PBM pays the pharmacy is passed through as the price paid by the plan sponsor to the PBM said to be "transparent pricing"
94
How to shop for a PBM
consultant RFP pick winning bid
95
Whats in a RFP
intro and client overview delegation of scope of services terms and definitions RFP questions pricing conditions performance guarantees
96
Use RFP to assess fit qualitatively
medicare part D operations compliance w/ state and federal regulations claims processing platform reporting platform customer service application audit provisions account term support
97
Tier model for part D components and definitions
range from 1-tier and 5-tier plans the higher the tier, the more enrollees pay
98
UM tools for part D components and definitions
fromulary verus non-formulary (NF) PA, ST, and QLs
99
Benefits for part D components and definitions
copays and/or coinsurance by tier and day supply phase - deductible, initial coverage limit (ICL), gap, and catastrophic
100
What is a rebate
retrospective discount off the cost of brand drugs paid by pharma manufacturer for preferential placement of a brand drug rebate guarantees usually based on rebates amount per brand drug claim metric
101
What can a DUR, DUE, MUE be used for
medication, therapeutic class, disease state or condition, med use processes
102
____ focusses more on pt outcomes and quality of life
MUE
103
___________ typically is more criteria-based assessment of appropriate med use processes and prescribing
DUE/DUR
104
Goals of DUR and DUE
improve med use processes across the managed care system encourage the practice of evidenced-based, clinically appropriate, cost-effective drug use identify trends in prescribing reduce drug misuse and abuse prevent adverse drug reactions
105
Pharmacists Role in DUR and DUE
identifies opportunities for quality improvement participates in effort to improve: pt outcome, quality of programs promotes appropriate drug use to reduce overall health carries out ethical and professional responsibility
106
Model of DUR program
access to member drug utilization data qualified pharmacists with authority to review knowledge of pop served and delivery system availability of established standards for comparison measurement of utilization review outcomes
107
Prospective DUR
screening method by which a health care provider reviews the necessity of drug therapy before it is dispensed or administered
108
DUR process
determine topic collect data data analysis perform intervention or provide feedback re-evaluate the program
109
Who benefits from DUR/DUE
plan member health care provider pharmacist health care system
110
Who do PBMs serve
corporate health plans health plans self-funded employers govt entities third party admin discount card/cash programs medicare part D individuals marketplace individuals
111
PBM pharmacist opportunities can be viewed in what 3 categories
clinical, operations, admin/corporate
112
Operations pharmacist opportunities
call center pharmacists and management mail service pharmacy speciality pharmacy PA case reviews/appeals MTM
113
Corporate pharmacist opportunities
account management clinical program development rebate management network management
114
Corporate/Admin pharmacist opportunities
account management informatics product development regulatory/compliance trade relations/rebate management data analytics/plan performance reporting
115
Speciality Pharmacy Providers (SPP)
provide clinical and distribution services to patients in the management of chronic, rare, or complex conditions

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