Rowe Section

Question 1

______ is a general term for organizations which utilize a variety of techniques to provide health care in a cost-effective manner.

Answer 1

Managed Care organizations.

Question 2

What are staff model MCOs

Answer 2

Employs physicians and may own clinics, hospitals, and pharmacies for exclusive use of their employees

Question 3

What is the independent practice association model (IPA)?

Answer 3

MCO contracts with independent physicians in the preferred provider organization (PPO).
—> Financial incentive to use preferred network of providers.

Question 4

What are the goals of MCOs?

Answer 4

1. Improve Quality of healthcare
2. Improve Accessability of healthcare
3. Improve healthcare outcomes
4. Improve patient quality of life
5. Contain Costs!!!

Question 5

What is the triple aim?

Answer 5

1. Quality
2. Satisfaction
3. Affordability

Question 6

How are MCOs measured for quality?

Answer 6

1. Health Plan Employer Data and Information Set (HEDIS)
2. New York Quality Assurance Reporting Requirement (QARR)
3. Centers for Medicare and Medicaid Services (CMS) Star Ratings

Question 7

What services do PBMs provide?

Answer 7

1. Claims processing
2. Assist with covered medication lists (formularies)
3. Review prior authorization requests
4. Pharmacy Network Administration

Question 8

What is the fastest growing component of healthcare?

Answer 8

Prescription drug costs
—> Growing faster than inflation.

Question 9

How does increasing prescription drug costs impact patients?

Answer 9

1. Increased Premiums
2. Increased copay/coinsurance costs

Question 10

What are the drivers of drug trends?

Answer 10

1. Better Diagnosis
2. Guideline Changes

Question 11

How do drug manufacturers influence prescription drug costs?

Answer 11

1. Free to set prices for medications
2. Price increases typically occur yearly
3. Historically, few interventions from legislator.

Question 12

How do drug coupons affect prescription drug costs?

Answer 12

They reduce costs to patients, but add to overall costs of medications.

Question 13

How do PBMs heavily influence drug costs?

Answer 13

1. PBMs have recently created “rebate aggressions” to move rebates outside PBM itself.
2. Consolidation of PBM industy gave PBMs large negotiating power.
3. Large PBMs have historically used rebates as a profit center. (so they demand high rebates)

Question 14

How do rare disease treatments influence prescription drug costs?

Answer 14

1. More targeted medications often used for a small subset of patients.
2. Less patients = Increased cost per treatment
3. Mostly new drugs—> Expensive!!!!

Question 15

Why should drugs which have received accelerated FDA approvals be used cautiously?

Answer 15

Drugs may not be as effective for general use as anticipated.
—> Studies may use surrogate endpoints!!!! to get accelerated approval.

Question 16

______ is a continually updated list of medications which represent the current clinical judgement of physicians, pharmacists and other experts in the diagnosis and preservation of health.

Answer 16

Formulary
—> Lists how plan covers medications
—> Clinically cost-effective medications will be placed preferentially.

Question 17

What is the difference between open and closed formularies?

Answer 17

Open = All drugs available

Closed = Only listed drugs available

Question 18

What is a P&T committee, how often must they meet?

Answer 18

—> Comprised of physicians and pharmacists

–> Mandated by government agencies

—> Group develops the formulary (tier placement, utilization management)

—> Meet at least quarterly to review newly approved medications.

Question 19

What is the overall objective of the P&T committee?

Answer 19

Cost Effectiveness

Question 20

What are factors the P&T committee considers?

Answer 20

1. Safety and Efficacy
2. The need for the drug
3. Effects on clinical outcomes
4. Multiple products in a class
5. Physician Acceptance
6. Only if multiple drugs have equal efficacies will cost be considered.

Question 21

What drugs are covered on tier 1 of a formularly?

Answer 21

Generics

Question 22

What drugs are typically covered on tier 2 of a formulary?

Answer 22

–> Significant clinical advantages for brands

—> First Line Therapy

–> A unique therapeutic agent for its approved indication

Question 23

What drugs are typically covered on tier 3 of an insurance formulary?

Answer 23

–> Default tier for new agents and “me too” drugs

–> Non-preferred drugs where utilization management is still needed.

–> Formularies may also include specialty and preferred generic tiers.

Question 24

What are some methods to change total plan cost?

Answer 24

—> Reducing coverage
—> Increasing employee contributions
—> Shifts to incentivized benefit designs
—> Coinsurance
—> Min/max per Rx
—> High deductible plans
—-> Out-of-pocket maximums

Question 25

What are prior authorizations?

Answer 25

---> Requires paperwork to be submitted by prescriber for review prior to a drug being covered. ---> Can be used to verify appropriate use. ---> Can be for safety reasons.

Question 26

What is step therapy?

Answer 26

Requires that certain medications are tried prior to covering others.

Question 27

What are quantity limitations?

Answer 27

Limits the quantity that is allowed to be fille?

Question 28

What is diagnosis editing?

Answer 28

Use of medical claims data to automatically review claims for appropriateness in real time --> Reduces administrative burden ---> Provides cost savings by curbing inappropriate use. Ex) Helps to reduce utilization of GLP-1RAs in patients without Type II diabetes diagnosis.

Question 29

What is a concurrent DUR?

Answer 29

1. Review drug history at time claim is filled. 2. Automatic edits in the system 3. Duplicative edits block similar medications 4. Safety edits to block severe contraindications 5. May require a prior authorization 6. May have a soft edit that a pharmacist may override.

Question 30

What is a retrospective DUR?

Answer 30

1. Review of past claims history to identify concerns. ---> Concurrent opioids and benzo ---> High Dose opioid prescribing for indication ---> Gaps in atypical antipsychotic use ---> Gaps in HIV retroviral therapy use 2. Typically to provide education to members and prescribers.

Question 31

How are specialty medications typically covered?

Answer 31

-->under medical or prescription benefit. --> Typically for clinically complex patients requiring additional care coordination. --> Require monitoring for dosing, side-effects compliance and administration. ---> Management of off-label use in light of clinical evidence.

Question 32

Why are specialty drugs concerning in regard to prescription drug costs. for insurance plans?

Answer 32

---> 1% of prescriptions BUT ---> 44% of total costs ---> Fastest rising portion of Rx costs trend ----> costs trending at 20%+ 5-8% of toal cost of medical benefit (50% of cost for cancer related treatment)

Question 33

Which specialty drugs are covered by prescription benefit?

Answer 33

Patient administered drugs

Question 34

Which specialty drugs are covered by medical benefit?

Answer 34

Clinician Adminsitered drugs

Question 35

Why is Hemgenix a specialty drug?

Answer 35

---> Gene therapy for hemophilia B ---> Costs ~ 3.5 million ---> Recieving hemlibra will make patient ineligble for other hemophilia B treatments. ---> for some hemophilia patients, the cost of blood factors can approach $1 million per year ----> Patients had a 54% reduction inbleeds the year after Hemgenix --> 94% of these patients discontinued prphylactic factor. *Basically although this drug is quite expensive, it actually reduces costs in the long-term*

Question 36

What is the generic first policy?

Answer 36

Every 1% increase in generic fill rate, may save 1.5% in drug costs. ---> Maintains quality care ---> Lowers trend without cost shifting to members ---> Lowers member contribution

Question 37

What are biosimilars?

Answer 37

--> A biologic drug that is nearly identical to an existing biologic drug (reference product) ---> Represents significant cost savings --->Most are not substitutable at the pharmacy (new rx needed) ---> competition also creates additional rebate opportunities.

Question 38

_______ requires insurers have an MTM program in place for most medicare part D plans?

Answer 38

CMS --> These comprise of a complete annual review of medications and quarterly follow ups. ---> Members on complex drug regimens can have better outcomes if involved in an MTM program.