Managed Care Practice & Measure of association Flashcards
(21 cards)
What is managed care organization? What is the method to achieve MCO’s goal?
Provide healthcare in` cost-effective manner by using a variety of methods, including:
- Financial risk arrangements with providers
- Provider networks
- Alternative payment models
- Utilization controls and monitoring
- PBD
How to achieve managed care goals?
Appropriate use of pharmaceuticals
Pharmacy Benefit Design
What is the triple aim?
Quality
Satisfaction
Affordability
What is IPA model?
Independent Practice Association model
Doctors are not employed by the staff model MCO but maintain their practices
Create a model with specialists, hospitals, labs, etc, part of MCO’s network
How do MCO measure for quality?
Health Plan Employer Data and Information Set (HEDIS)
New York Quality Assurance Reporting requirement
CMS Star ratings
What factors contribute to the rise of cost
Aging population
Better diagnoses
Guideline changes
What disadvantages of drug coupons?
Reduce costs to patients BUT add to overall cost medication
Induce demand for higher cost vs efficacy products
What method to maintain appropriate use - utilization management?
Prior Auth
Step therapy
Quantity Limits
Diagnosis Editing
Concurrent DUR vs Retrospective DUR
Concurrent: review claims at the time filled for duplicative therapy & severe contraindication
Retrospective: past claims history to identify drug problems
Sensitivity vs Specificity
Sensitivity: ability to identify correctly ppl who have disease
Specificity: ability to identify correctly ppl who DO NOT have disease
200 ppl took a rapid antigen test (COVID test). 50 ppl tested positive and 150 ppl tested negative.
But, only 40 ppl tested true positive and 140 ppl tested true negative
Calculate selectivity & specificity
Selectivity: 0.8
Specificity: 0.93
What value use to describe morbidity?
Prevalance
Incidance rate
Attack rate
Incidence rate vs Prevalence
Incidence: number of new cases in a population at risk for developing a disease (excluding pre-existing disease)
Prevalence: number of present cases of a disease in a population
ICU admitted 500 ppl
30 ppl already have pneumonia
9 ppl newly diagnosed with pneumonia
Calculate incidence rate
Incidence: 1.91
What is attack rate?
number of cases of a disease got from exposure over number of cases got exposed
standardization meaning
Direct vs Indirect standardization
Method to compare the rate of disease or death between populations with different backgrounds (ages, sex, etc) to make fair comparisons
Direct: estimate the rate of disease in a population as it had the same age distribution as a standard population
Indirect: compared the observed rate of disease to the expected rate based on standard population
Risk ratios vs odds ratios
Risk ratios are used in prospective cohort studies
Odds ratios are used in retrospective, case control studies where total number of exposed ppl is unknown
- Multiple logistic regression
What attributable risk?
Amount or portion of disease that increase due to an exposure
Ex: total ppl have lung cancer and smoke - total ppl have lung cancer and non-smoker = attributable risk
what is population attritutable risk?
Attributable risk of an entire population whether or not all in the population have direct exposure
Ex: 12.5% PAR in a study assessing the relationship between smoking and low birthweight
If everyone quits smoking, cases of low birth weight would decrease by 12.5%
What is hazard ratio commonly used in?
Survival analysis
NNT vs NNH desire
NNT: the lower, the more ppl can be benefit
NNH: The higher the better bc it’s the number of patients who receive treatment before 1 adverse event occurs
