pop health (up to SPs)

Question 1

what is a HC effectiveness data and information set?

Answer 1

a measure of health plans performance based on
- effectiveness of care
- access/availability of care
- experience of care
- utilization and relative resource use
- health plan descriptive data

Question 2

which act expanded on HMOs?

Answer 2

HMO act of 1973
promoted wellness and health prevention in addition to comprehensive acute and chronic care

Question 3

what are examples of utilization management tools of prescription drug plans?

Answer 3

PAs
step therapy
quantity limits

Question 4

what is tier 1?

Answer 4

no OR lowest copayment (most generic drugs)

Question 5

what is tier 4/speciality tier?

Answer 5

highest copayment
high-cost non-preferred prescription medications

Question 6

what is conventional insurance?

Answer 6

high premium
few if any restrictions

Question 7

what are HDHP/SO?

Answer 7

high deductible managed care plan with savings option
usually with incentives to use certain facilities and providers (PPO or POS)

Question 8

what is the most common health plan in the US for covered workers?

Answer 8

PPO

Question 9

what type of employers is most affected by GP1-agonists?

Answer 9

those with 5,000 or more works are spending the most on prescription drugs

Question 10

what type of insurance payment has increased the most since 2013?

Answer 10

deductibles

Question 11

what is a flexible spending account (FSA)?

Answer 11

deduct pre-tax money from your paycheck for eligible HC expenses
max 4,300 per year
must be used in calendar year or forfeited

Question 12

what is health reimbursement arrangement (HRA)?

Answer 12

employer-funded account used to reimburse for eligible HC expenses
must be used in calendar year or forfeited

Question 13

how much do employers typically pay in total annual salary for benefits?

Answer 13

25-30%

Question 14

why do people need health insurance?

Answer 14

HC is expensive and unpredictable

Question 15

what is fully-insured health plan?

Answer 15

insurance company assumes risk of providing health coverage for insured events
employers pay a per-employee premium to an insurance company
usually offered by smaller employers

Question 16

what are self-insured health plan?

Answer 16

employer assumes risk of providing health coverage for insured events
employer acts as own insurer
claims often processed by an insurance company
can lower costs, maximizes income, avoids state health insurance premium taxes and mandated benefits
allows customization of plans, employer is free to contract with any provider
usually offered by larger employers

Question 17

what is the average sales price (ASP)?

Answer 17

medicare pt in hospital
usually medical provider is paid using a formula of this + 6%

Question 18

what drug class is the top per member per month cost?

Answer 18

behavioral health

Question 19

what is unique about vraylar (cariprazine)?

Answer 19

most expensive drug for behavioral health for insurance plans

Question 20

what is the top category of drugs in the top 25?

Answer 20

diabetes

Question 21

what is the top speciality drug?

Answer 21

humira (and dupixent)

Question 22

how are PBMs paid?

Answer 22

as a percentage of retail drug prices
incentivized to exclude lower cost drugs and promote higher cost meds

Question 23

where do PBMs profit the msot?

Answer 23

speciality pharmacy and increasingly admin fees

Question 24

what are group purchasing organization (GPOs)?

Answer 24

contract directly with drug manufacturers
PBMs in disguise, owned by PBMs but claim to contract for the PBM

Question 25

what are other characteristics of GPOs?

Answer 25

helps to aggregate and leverage purchase volume to negotiate discounts with manufacturers and distributors takes possession of the product members still have choice but there is power in commitment and compliance data and analytics driven

Question 26

what is descriptive data?

Answer 26

tells what happened example -- inventory trends, disruption analysis, and usage

Question 27

what does diagnostic data tell?

Answer 27

why did it happen example --> shipment delays, order fulfillment, inventory turnover

Question 28

what does predictive data tell?

Answer 28

what will happen example --> raw material tracking, inventory management, pricing, competitiveness

Question 29

what does prescriptive data tell?

Answer 29

what should I do example --> market intelligence, strategy guidance

Question 30

what is unique about injectables?

Answer 30

dosage form that accounts for the largest share of shortages

Question 31

what is drug supply chain secuirty act (DSCSA)?

Answer 31

federal regulation that outlines steps to achieve an interoperable and electronic way to identify and trace certain rx drugs at the package level as they move through the supply chain

Question 32

how is the VA funded?

Answer 32

primarily through federal income taxes

Question 33

what is the veterans equitable resource allocation (VERA)?

Answer 33

per-capita distribution model based on number of veterans in catchment area have primary facility they are linked to based on where primary care is provided may seek speciality care at other VA facilities medical complexity of each veteran is taken into account

Question 34

what regulations are followed at the VA?

Answer 34

federal pharmacy regulations pharmacist can be license in any state

Question 35

can mail VA pharmacies fill C2s?

Answer 35

no

Question 36

what is the VA national formulary?

Answer 36

tier 1 --> $5 preferred generics tier 2 --> $8 non-preferred generics tier 3 --> $11 brand name/biologics max out of pocket expenses at 700 per year PA can be local, VISN, or national level

Question 37

what did the MISSION act do?

Answer 37

expanded and redefined the circumstances in which veterans can receive medical care outside of the VA increases outside Rx, urgent and emergent prescription fails, and workflow is now more akin to community pharmacy

Question 38

what is the primary care almanac?

Answer 38

stratifies a panel of pts based on various disease state outliers

Question 39

what is the pt aligned care teams (PACT) compass?

Answer 39

stratifies a panel of pts based on diagnosis

Question 40

what is care assessment needs (CAN) score?

Answer 40

estimated probability of admission or death in a specified period of time

Question 41

what is the medication use evaluation trackers?

Answer 41

identifies target pts that meet pre--set criteria for intervention

Question 42

what is the largest category for drugs in speciality pharmacy?

Answer 42

oncology

Question 43

what is speciality medication?

Answer 43

medications for small populations medications for rare disease high cost meds special handing requirements not just injectables

Question 44

what is open distribution speciality pharmacy?

Answer 44

manufacturer wants everyone to have access inconsistency of services and most expensive lowest level of control

Question 45

what is controlled distribution speciality pharmacy?

Answer 45

manufacturer wants to control access lower infrastructure costs consistent services flexible less product access choice

Question 46

what are PBM-owned specialty pharmacy?

Answer 46

high access to lives medium service level high costs and account management

Question 47

what are independently owned speciality pharmacies?

Answer 47

medium/low access to lives high service level medium cost

Question 48

what are payor owned specialty pharmacy?

Answer 48

high access to lives and service level medium costs

Question 49

what are small-medium sized owned SPs?

Answer 49

low/medium access to lives medium/high service level medium cost low account management

Question 50

what are large chain SPs?

Answer 50

medium/high access to lives medium/high service level medium cost low account management

Question 51

what are hospital/outpatient SPs?

Answer 51

medium access to lives medium/high service level medium cost