pop health (up to contracts)

Question 1

what is the indiana network for patient care (INPC)?

Answer 1

data on over 18 million pts from over 100 separate HC entities providing rx drug data, encounter records, clinical observations, etc

Question 2

what is a confounder?

Answer 2

a variable that is independently related to both the tx and the outcome
want to avoid these in trials

Question 3

what is information bias?

Answer 3

bias related to information regarding exposure or outcome
includes measurement or classification error

Question 4

what is detection bias?

Answer 4

specific outcome is diagnosed preferentially in subjects exposed to the agent
ex. may be more likely to look for an AE in someone who is exposed to a drug

Question 5

what is confounding by indication?

Answer 5

indication for a drug or severity of a disease predicts the use of a drug
ex. ACEi in preventing Mi in pts with HTN
ex. COXib and GI bleeds

Question 6

what is selection bias?

Answer 6

related to procedures used to select subjects/influence study participations
due to systematic differences in characteristics between those who are selected for a study and those who are not

Question 7

what is referral bias?

Answer 7

reason for encounter is related to drug tx
ex. when the use of a drug contributes to the diagnostic process

Question 8

what is protopathic bias (reverse causality)?

Answer 8

exposure of interest is used unknowingly to tx an AE related to outcome/agent is used for early manifestations of a disease that has not yet been diagnosed
tx was stopped, started, or changed because of baseline manifestation caused by a disease or other outcome event (started in response to first symptoms of disease which was undiagnosed)

Question 9

what is an example of protopathic bias?

Answer 9

an antipsychotic therapy may be started to tx delirium, but the drug may have anticholinergic effects that contribute to delirium

Question 10

what is prevalence bias?

Answer 10

prevalent cases rather than new cases are selected

Question 11

what is immortal time bias?

Answer 11

period of follow-up when, due to exposure definition, the outcome being studied could never occur
heart transplant study example (ppl on transplant list group who died were automatically put in the control group, modifying the outcome)

Question 12

what is the opioid study from class show?

Answer 12

restrospective cohort study
factors associated with problematic opioid use were studied
opioid naive adult medicare pts 65+
greater than 60 day opioid therapy

Question 13

what is the FDA AE reporting system (FAERS)?

Answer 13

houses postmarketing AE reports received by FDA
MedWatch reports included

Question 14

what is the FDA Sentinel system?

Answer 14

monitors safety of FDA regulated prodcuts
data submitted by multiple sources (clinical, academic, claims, others)

Question 15

what is efficacy?

Answer 15

whether a drug has the ability to bring about a given intended effect in controlled settings

Question 16

what is effectiveness?

Answer 16

whether, in real-world pts and settings, a treatment, in fact achieves its desired effect

Question 17

what is managed care organization?

Answer 17

manage the cost and utilization of covered services and products to optimize pt care through efficient use of limited resources

Question 18

what are accountable care organizations (ACOs)

Answer 18

groups of doctors, hospitals, and other HC providers who voluntarily work together to provide coordinated high-quality care to their medicare pts and accept financial risk/reward tied to clinical outcomes

Question 19

what are preferred provider organizations (PPO)?

Answer 19

managed care delivery model consisting of preferred networks of providers with some out of network coverage
offer pts more choice and flexibility than health maintenance organizations with correspondingly higher premiums

Question 20

what is a point of service plan (POS)?

Answer 20

health insurance plan that allows you to choose between in-network and out-of-network providers
combination of HMO and PPO plans
offer flexibility when you need care
have lower premiums than PPO

Question 21

what is deductible?

Answer 21

fixed amount that an insure person must pay out of pocket before HC benefits become payable
usually expressed in terms of annual amount

Question 22

what is a premium?

Answer 22

the amount paid to a health insurance carrier for providing coverage under a contract

Question 23

what is co-insurance?

Answer 23

the percentage of cost of HC services/products by the pt after deductible

Question 24

what is a co-payment?

Answer 24

a cost-sharing arrangement in which a covered person pays a specific charge for a specific service such as a fixed dollar amount for each prescription received
ex. $5 per generic prescription
usually paid when the service/product is provided

Question 25

what are out-of-pocket costs/expenses?

Answer 25

portion of payments for covered health services required to be paid by the enrollee, including co-payments, coinsurance, and deductibles

Question 26

what are copay coupons/cards?

Answer 26

discount cards provided by pharmaceutical manufacturers to pts to reduce pt cost-share for prescriptions (or first fill of several refills) of non-preferred drugs for a certain period of time

Question 27

what is health savings account (HSA)?

Answer 27

a tax-sheltered account that may be used by beneficiaries covered by high-deductible health plans (HDHPs) to pay for routine health care expenses

Question 28

what is dossier?

Answer 28

standardized by AMCP for manufacturer's submission of clinical and economic evidence in support of formulary consider manufacturers and MCOs use the format to formalize, standardize, and expand info for P&T committee review

Question 29

what is a preferred drug?

Answer 29

drug designed by MCO as a valuable, cost-effective treatment option in multiple-tiered pharmacy benefit plans, these are assigned to a lower tie

Question 30

what is a drug mix?

Answer 30

evaluation of the type of drugs prescribed by an individual or defined population may reveal the rate of new drug adoption by reviewed physicians

Question 31

what is a carve-out pharmacy benefit?

Answer 31

the separation of a service (or a group of services) from the basic set of benefits in some way the plan sponsor separates the pharmacy benefit from the medical benefit and hires a PBM to provide and manage these benefits

Question 32

what is an average wholesale price?

Answer 32

historically, generally accepted drug payment benchmark for many payers now, sticker price that rarely reflects the actual payment after discounts have been subtracted usually 20% higher than wholesale acquisition cost (WAC) but may vary

Question 33

what is the maximum allowable cost (MAC)?

Answer 33

a reimbursement limit per individual multiple-source pharmaceutical entity, strength, and dosage form price lists are established by health plans and PBMs for private-sector clients and usually are considered confidential

Question 34

what is the national committee for quality assurance (NCQA)?

Answer 34

private, not for profit organization dedicated to improving HC quality develops a rigorous set of quality standards and performance measures for the accreditation of a broad range of HC entitites

Question 35

what are outcomes-based contracts?

Answer 35

pharmaceutical manufactures provide rebates based upon drug failure to provide specified outcomes to help mitigate financial risk of new drugs with unknown real-world clinical experience

Question 36

what is a PBM?

Answer 36

organization that manage pharmacy benefits for MCOs, other medical providers, or employers activities may include: benefit plan design, creation/administration of retail and mail service networks, claims processing, and managed prescription drug care services

Question 37

what is a PA?

Answer 37

administrative tool used by health plans or PBMs that require prescribers to receive pre-approval for certain drugs to quality those drugs for coverage under the terms of the pharmacy benefit guidelines and administrative policies for this are developed by pharmacist and/or other qualified health professionals who are employed by or under contract with a health plan or PBM

Question 38

what is a rebate?

Answer 38

a discount that occurs after drugs are purchased from a pharmaceutical manufacturer and involves the manufacturer returning some of the purchase price to the purchaser when drugs are purchased by a managed care organization, this is based on volume, market share, and other factors

Question 39

what is access rebate?

Answer 39

smaller percentage flat/fixed percentage off WAC in exchange for formulary listing or favorable position

Question 40

what is performance rebate?

Answer 40

higher percentage variable percentage off WAC based on achieving specific performance parameters, usually based on market shares increases

Question 41

what is a portfolio rebate contract?

Answer 41

manufacturer with a large number of drugs offer individual drug rebates and extra portfolio incentives to a MCO for accepting multiple drugs by formulary addition

Question 42

what is a bundle rebate contract?

Answer 42

manufacture offers a rebate on a desirable drug only if the MCO adds one or more other undesirable drugs to the formulary