U.S Healthcare exam 2

Question 1

Ethics in Practice

what does the Institutional Review Boards (IRBs) do

what do ethics committees do in hospitals

what do compliance officers do

what was first published in 1852

Answer 1

Institutional Review Boards (IRBs) –required to approve all investigational research involving human subjects to ensure their ethical treatment

Ethics Committees in hospitals can act as consultants for difficult or recurrent ethical cases

Compliance officers in corporations and managed agencies –report directly to the CEO

Code of Ethics for Pharmacists (first published 1852)

Question 2

Principles of Medical Ethics

Beneficence is the duty of healthcare providers to do what

Nonmaleficence is the duty of healthcare providers to do what

Autonomy gives the patient the right to do what

Justice is the concept of treating people with what

Answer 2

Beneficence – obligation of healthcare providers to help people in need; duty to help others

Nonmaleficence – duty of health care providers to “do no harm”

Autonomy – right of the patients to make choices regarding their health care

Justice – concept of treating everyone in a fair manner

Question 3

In the previous example, which ethical principle is being violated from the perspective of the patient?

Beneficence
Nonmaleficence
Autonomy
Justice

Answer 3

Autonomy

Question 4

Ethical dilemmas

the provider is forced to do what

when does this often occur

Answer 4

Provider of medical care is forced to make a decision that violates one of the four principles of ethics

Often occur when you run out of options

Question 5

Ethical Dilemma

From the earlier example, the medical resident’s desire to treat the patient with standard medical therapy demonstrates the principle of beneficence

Not giving proven effective therapy in this patient can cause serious harm – the resident wants to treat the patient and help them survive
This case is unique because the doctor is being prevented from giving care he would have given to almost any other patient in the same situation

what does the desire to not receive blood represent

Answer 5

For the patient, the desire to not receive blood products represents the principle of autonomy

Question 6

Social-ethical dilemmas

what is connected to in reference to what

some patients are unable to receive needed care, why?

Answer 6

Connected to the concept of justice

Justice in reference to access to basic medical care

Some patients unable to receive needed care because they lack money and insurance or resources in their area

Question 7

Distributive Justice

when does issue arise

what questions does it ask about right, care, taxes etc

all people should have what kind of access without financial barriers if healthcare was distributed based on what

what is always debated in the US about rights and privileges

Answer 7

Issue arises when money and resource become scarce

Allocation of the benefits and burdens in society
Is healthcare a privilege or a right? Who receives care? Who pays taxes? Who decides?

All people should have equal access to a reasonable level of care without financial barriers
If healthcare should be distributed based on need for care

In the US, the belief of healthcare as a right versus a privilege continues to be a debate

Question 8

Rationing will be on exam

Answer 8

The limitation of resources, including money, going to medical care such that not all care expected to be beneficial is provided to all patients; and the distribution of these limited resources in a fair manner.

A conscious policy to equitably distribute limited resources
Urgent MRI scan versus an elective scan
Organ transplant waitlists
Available hospital beds
Drug shortages (or even IV bags)

Question 9

Scarcity – not enough to go around

what is there a scarcity of

Answer 9

Scarcity of Commodity

Scarcity of Money (fiscal)

Scarcity of Resources

Question 10

Scarcity of Commodity

what is one example of this matter

how is it address

what can impact the example

what is not donated enough

what question is always being asked

Answer 10

Organ transplantation

Addressed through macroallocation (society/large population) process, life style can affect candidacy – if you drink then you will probably not qualify because they see it as a waste

There are not enough organs donated to meet demand
135,000 patients waiting for an organ in 2015

Example of the interaction of ethics and rationing
Who should receive available organs??
United Network for Organ Sharing (UNOS)

Question 11

Rationing and microallocation

what is there is constraint on

for covid 19 and ventilators what was alway questioned

Brings ethical principles into focus, sometimes tragically
Older patients with co-morbidities and poor prognosis may not receive potentially life saving therapy due to a lack of resources

Answer 11

Resource constraints on an institution or physician level

COVID-19 and rationing on the institution level

Not enough ventilators for all patients requiring support
Who gets mechanical ventilation?

Not enough vent technicians to monitor the ventilators being used

Who gets moved from one department to fill the gap? Is this even possible?

Question 12

Rationing Healthcare

If rationing a beneficial service is necessary, medical effectiveness can help guide what

Maximizing care for healthy/screening increases resources for who

when Managing chronic diseases Medication adherence, what is usually considered

Oregon Health Plan – Rational rationing
Prioritized care for certain diagnoses and expanded coverage to 100K more patients
Plan unraveled

Answer 12

If rationing a beneficial service is necessary, medical effectiveness can help guide choices

Providing care when healthy vs care when sick

Maximizing care for healthy/screening increases resources for those who are sick

Managing chronic diseases
Medication adherence (beneficence vs autonomy)

Question 13

Rationing and cost control

Answer 13

Controlling cost does not equal rationing of healthcare

Difference between reducing unnecessary interventions or eliminating administrative waste and a compromise in truly beneficial services

Question 14

Summary of lecture 1 of unit 2

what can be said about ethical dilemmas

what will healthcare always struggle with

Answer 14

Ethics and ethical dilemmas play a role in many healthcare decisions that are made on a daily basis

Healthcare always will struggle with balancing care to individual patients with responsibly managing resources

Question 15

Cost of Healthcare

Answer 15

Last lecture you discussed cost trends, costs vs outcomes, price x quantity, and reviewed ways to control costs

Multiple drivers of health care cost
Overuse or inappropriate utilization
Inefficient payment systems
High prices
Excessive administrative cost
Medical liability
Declining health status in the population / chronic disease

Uncontrolled costs may lead to inaccessible and inequitable care

Question 16

How to Contain Costs

Answer 16

Decrease use of healthcare services

Decrease reimbursement for service

Decrease overhead (payer and/or provider)

Question 17

Cost Control – Follow the money

Answer 17

payers to health plan to providers

Question 18

Financing Controls: Regulatory Strategies:

passing what or creating what

medicare part ___

affordable care ___

Answer 18

Passing laws or creating taxes

Medicare Part A
Social insurance systems
Regulated by Federal government
Medicare payroll tax 2.9%

Affordable Care Act (ACA)

Question 19

Competition Considerations…

who’s buying

does it work?

Answer 19

Who’s buying?
–Employer based insurance blunts the high cost of insurance
–Cost of health insurance paid by employer not seen as lost wages
–A federal tax exemption increases value for the employee and savings for the employer

Does it work?
–Premiums continue to grow at about 5% per year
–Competition has not truly been implemented in most markets

Question 20

Weakness of financing controls

Answer 20

To be successful, they must produce decreased flow on the payment side

If payment to physicians, hospitals, and other providers increases, the budget deficits must be offset by increased taxes

Insurers may raise premiums if they cannot control what they pay to hospitals

Competition places emphasis on private health insurance to regulate payment costs

Question 21

Payment: Price controls

what is set

what is an example of this

these fees set by Medicare may impact what a patient

Answer 21

Set reimbursement rates (ie: Canada, Medicare)

–Uniform fee schedule (fee-for-service)
- A list of fees used to pay doctors/providers for services
- These fees set by Medicare may impact the care patients receive

Question 22

Payment: Price controls

Answer 22

Predetermined pricing for services
Competitive bidding between private insurance plans
Reference pricing

Example:
Choice Ref PPO asks each hospital in its market region to submit a bid for the cost a knee replacement. Most bids are around $40,000. High Value Hospital submits a bid for $33,000. Choice Ref informs patients enrolled in their plan that they can choose any hospital for a knee replacement, but that they will only pay the hospital $35,000 and the patient is responsible for the rest. After this policy, 75% of Choice Ref patients get knee replacements at High Value Hospital.

Question 23

Problems with price control

cost shifting

patient churning

why is it hard for patients to find providers who accept medicaid

what does it result in

Answer 23

Cost shifting – Increasing charges to other payers to compensate for lowering the cost for one payer
Problem often avoided using uniform fee schedules or single payers

Patient churning - Inducing higher use of services (more visits/procedures/etc) to offset the lower price with higher volume in order to maintain earnings

Example: Medicaid fee-for-service pays physicians far below private insurance rates
Difficult for patients to find providers who will accept Medicaid
Results in patient churning, reduced quality of care, reduced patient satisfaction

Question 24

Utilization Controls

what do payers need methods to do

what are the 3 methods to consider

Answer 24

Payers (ie: the health insurance) need methods to contain how often their customers (ie: the patients) use healthcare resources

Three methods to consider
Unit of payment
Patient behavior
Physician behavior

Question 25

Patient Cost sharing what is the primary intent what does it discourage both of what may this system reduce who does it have little effect on

Answer 25

Cost sharing at point of service – primary intent to discourage patient demand for services - Discourages both appropriate and inappropriate care May effectively reduce costs US has cost sharing but the highest overall cost Little effect on the most costly/extremely ill Pharmacy and co-pays Joe pays $20 each time he fills one prescription and the insurance pays for any cost above $20. Because Joe is on multiple medications for chronic disease, he pays $1200 per year on his copayments.

Question 26

Utilization Management what are people denied payment for Thelma Graves suffers from a severe hyperthyroid condition; she and her physician agree that she will undergo thyroid surgery. Before scheduling the surgery, the physician has to call Ms. Graves’ insurance company to obtain preauthorization, without which the insurer will not pay Fred is hospitalized for an acute MI. The hospital contacts the management firm for Mr. Brady’s insurer, which authorizes 5 hospital days. On the 4th day, Mr Brady develops a complication requiring a temporary pacemaker and additional 10 days in the hospital. After the 5th day, the physician has to call the management firm every 2 days to justify why the insurer should continue to pay

Answer 26

Denial of payment for unnecessary services

Question 27

Supply limits what does it depend on what does supplier induced demand equal and thus equals what and this equals what what are there limited resources of where can this occur

Answer 27

May depend on the number of caregivers Supplier induced demand = more surgeons equals more surgery Limited resources (MRI scanners, hospital beds, etc.) Can occur within a health system (HMO) or geographic region

Question 28

Supply limits Bob, in Canada, develops back pain. After several visits the family physician requests an MRI to rule out disk disease. His physician, who does not suspect disk herniation, puts him on a 5 month waiting list for an MRI. Rob, in Canada, after lifting 40 kg at work, experience severe back pain radiating down his leg. Finding a positive straight-leg-raising test with loss of ankle reflex, his physician calls and obtains an emergency MRI scan within 3 days.

Answer 28

just understand the example I guess...

Question 29

Summary of lecture 2 The key to cost control in the United States… “is not in the micromanagement of the doctor-patient relationship but...

Answer 29

the management of capacity and budgets. The American problem is to find the will to set the supply thermostat somewhere within reason.” -Dr. John Wennberg

Question 30

lecture 3 objectives Describe the four parts of Medicare Identify the benefits including the medications and immunizations covered under each part of Medicare Recall the two types of plans that provide Medicare Part D coverage Define terminology associated with Medicare Part D Explain fraud, waste, and abuse as it relates to Medicare

Answer 30

Describe the four parts of Medicare Part A: Inpatient Medical Insurance Part B: outpatient medical insurance Part C: a medical advantage that includes A, B, and part of D Part D: medicare prescription drug coverage, need to add thru a private company Identify the benefits including the medications and immunizations covered under each part of Medicare - Recall the two types of plans that provide Medicare Part D coverage Define terminology associated with Medicare Part D Explain fraud, waste, and abuse as it relates to Medicare Fraud: Intentional misrepresentation of information for financial gain waste: overuse of services, unintentional abuse

Question 31

what is the History of Medicare

Answer 31

In 1965, President Lyndon B. Johnson signed the Social Security Act of 1965 establishing Medicare and Medicaid Older and lower income individuals could not afford to purchase private health insurance Established health insurance where the cost of health insurance was spread across tax payers in the US

Question 32

What is Medicare?

Answer 32

A federal health insurance program that helps with the cost of healthcare in the US Covers some medical expenses but not all; is not comprehensive

Question 33

Who is enrolled in Medicare? no need to memorize numbers but know....

Answer 33

64.5 million people are enrolled in Medicare (CMS, 2022) 56.6 million are 65 years or older (88%) 7.9 million are disabled (12%) 80 million people expected to be enrolled by 2030 Medicare beneficiaries as percentage of total population (19%) New Hampshire: 23% Massachusetts: 20% Maine: 26% (Highest!) (KFF, 2022) know that a lot of people are on it!

Question 34

Who is eligible for Medicare? 65 years and older Under 65 years *important to know*

Answer 34

65 years and older - 65 years and older Under 65 years - - Receiving social security disability Insurance for 24 months or - diagnosed with End-stage Renal Disease (ESRD) or Amyotrophic lateral sclerosis (ALS)

Question 35

Medicare Has 4 Parts' Each part of Medicare covers different services Part A Part B Part C Part D

Answer 35

Part A: Hospital Insurance Part B: outpatient insurance Part C: medical advantage which has A, B & some of D Part D: medicare prescription drug coverage

Question 36

Two ways to receive Medicare benefits original medicare medicare advantage

Answer 36

Original Medicare - part A, B & D Medicare advantage - part C (includes part A, B, most often D)

Question 37

Original Medicare Medicare Advantage (Part C)

Answer 37

Original Medicare - Includes Medicare Part A and/or Medicare Part B coverage - Can add Medicare Part D plan for drug coverage Medicare Advantage (Part C) - Includes Medicare Part A and Medicare Part B and usually Part D coverage

Question 38

Part A covered services

Answer 38

Inpatient hospital care Skilled nursing facility (SNF) care Home health care Hospice care Short-term nursing home care Medications prescribed during an inpatient hospital or SNF stay Part of treatment plan Medications prescribed during hospice care Used for symptom or pain relief Does not cover medications for chronic conditions

Question 39

Part B covered services *should know for exam*

Answer 39

Outpatient medical care, preventative care, mental health services physical therapy outpatient surgical services and supplies lab tests durable medication equipment ambulance services home health care diabetic testing supplies (blood glucose monitor, test strips. lancets)

Question 40

Part B covered medications *need to know*

Answer 40

Injectable and infusible drugs given in a provider's office Nebulized solutions and medications used in infusion pumps Oral cancer and anti-nausea drugs Immunosuppressive drugs used to sustain a covered transplant Insulin used in a pump

Question 41

Part B covered immunizations *should know this*

Answer 41

flu hepatitis B (high or intermediate risk) tetanus (injury related) pneumonia covid-19 rabies (exposure)

Question 42

MedicarePart D

Answer 42

Prescription drug benefit Provided by private insurance companies Voluntary but if don't enroll and do not maintain creditable coverage may experience a penalty in future Plans vary by medications covered and associated costs Open Enrollment is from October 15th through December 7th annually

Question 43

Part D covered medications

Answer 43

Prescription brand and generic medications - - Must be approved by the FDA and used for medically accepted indications and sold in the United States Includes drugs, biologics, insulin and the supplies associated with the injection of insulin Generally, must cover at least two drugs in each therapeutic category Formularies must include all medications from six protected therapeutic categories - - Antidepressants, antipsychotics, anticonvulsants, anticancer medications, immunosuppressants, and HIV/AIDs medications

Question 44

Medications excluded by MedicarePart D

Answer 44

Anorexia, weight loss, or weight gain medications Erectile dysfunction drugs when used for sexual or erectile dysfunction Fertility drugs Cosmetic and lifestyle drugs Medications used for symptomatic relief of cough and cold Prescription vitamins and minerals Over-the-counter medications Medications that must be administered by a health professional Most medications used in a durable medical device

Question 45

MedicarePart D covered immunizations

Answer 45

shingles tetanus (prevention) hepatitis B (low risk) RSV- full cost >$150

Question 46

Case Example Spring is here and Lee has started working on his gardening shed. While fixing the shed, Lee stepped on a rusty nail and needed to immediately go to an outpatient clinic for a tetanus shot. Will Medicare Part B or Part D pay for the tetanus shot? Answer:

Answer 46

Part B because it is injury related

Question 47

Case Example Emma needs to pick up supplies and medicine for the management of her diabetes.  She needs blood glucose testing supplies, syringes for the injection of insulin, and a 10 ml vial of Novolog insulin. Which part of Medicare covers the following supplies? blood glucose testing supplies syringes nonovlog insulin 10 mL vial

Answer 47

blood glucose testing supplies_ B syringes- D novolog insulin 10 mL vial - D if pumo them B

Question 48

Medicare Part C

Answer 48

Another way to get your Medicare coverage (often called Medicare Advantage) Must be enrolled in Part A and B to join Coverage is provided by private companies that provide your Medicare A, B, and often D coverage Usually offered as an HMO or PPO Must live in plan’s service area to enroll May provide additional benefits like gym membership, wellness classes, dental coverage, vision services

Question 49

Medicare Part D Terminology premium deductible initial coverage coverage Gap/donut hole catastrophic coverage

Answer 49

premium: monthly payment to belong to insurance plan deductible: annual amount to pay before coverage begins. patient must pay for total cost of drugs up to this amount before standard copayment or coinsurance begin initial coverage: patient pays standard plan copayment (like $10) for prescriptions on a tier or coinsurance (like 25% of the cost of the prescription) on a tier coverage Gap/donut hole: when benefit stops after a certain spending limit is reached. patient stops paying standoff copayment sand start paying coinsurance (brand: 25%; generic: 25%) catastrophic coverage: begins when a out of pocket spending limit is reached

Question 50

phase - deductible - initial coverage level (after deductible and before $4,660 in total drug costs) - coverage gap (when $4,660 in drug costs is achieved) - catastrophic coverage (when $7,400 in out of pocket drugs costs is met) cost of beneficiary for medications

Answer 50

cost of beneficiary for medications deductible - $505 initial coverage level - copayment or 25% coinsurance coverage gap - 25% catastrophic coverage - $4.15%/$10.35 or 5%, whichever is higher

Question 51

Medicare Part D and the Inflation Reduction Act

Answer 51

2023 changes Insulin copayments will be limited to $35/month Eliminates cost-sharing associated with vaccines covered under Medicare Part D

Question 52

Pharmacists and Medicare

Answer 52

Pharmacists play a vital role in protecting the integrity of the Medicare program. Misuse and fraud of Medicare dollars by providers AND patients puts financial stress on an already strained program and places health and wellness of beneficiaries at risk Annual training required at many facilities to prevent fraud and abuse

Question 53

Medicare Fraud, Waste, and Abuse fraud waste abuse

Answer 53

fraud - Intentional misrepresentation of data for financial gain - Knowingly use false information to gain a payment or benefit Waste - Overuse - Careless or needless use of health care benefits and resources - Not intentional abuse - Receiving payment for benefits or services without misrepresenting data that results in unnecessary costs to Medicare programs - Not intentional

Question 54

Examples of FWA  (fraud waste and abuse) Intentionally billing for administration of vaccine that you did not give = Unintentionally billing duplicate times for one service and received payment for benefits = Intentionally billing for a more costly service than performed = Intentionally using someone else's insurance coverage for services = Unintentionally billing an inhaler that a patient does not need when he/she was admitted to the hospital =

Answer 54

Intentionally billing for administration of vaccine that you did not give = Fraud Unintentionally billing duplicate times for one service and received payment for benefits=Abuse Intentionally billing for a more costly service than performed= Fraud Intentionally using someone else's insurance coverage for services=Fraud Unintentionally billing an inhaler that a patient does not need when he/she was admitted to the hospital=Waste

Question 55

Penalties and Consequences

Answer 55

False Claims Act - Fraud Criminal and/or civil prosecution or prison time Suspension of provider license and/or Medicare provider status Will not be able to get hired Exclusion from Medicare program and/or government contracts Financial penalties

Question 56

Conclusion medicare medicare terms medicare FWA pharmacy in practice

Answer 56

Medicare - The four parts of Medicare are Part A -hospital insurance; Part B – medical insurance; Part C - Medicare Advantage Plans which includes Part A, Part B, and Part D; Part D – Medicare prescription drug coverage Medicare terminology - Medicare Part D plans include premiums, deductibles, initial coverage payments which are usually copays but can be coinsurance, a coverage gap or donut hole in which patient pays coinsurance, and catastrophic coverage - Medicare fraud, waste, and abuse Pharmacists play a role in protecting the integrity of the Medicare program and annual training is required at many facilities - In pharmacy practice, you will be working with many Medicare beneficiaries!

Question 57

HMO- Health Maintenance Organization

Answer 57

a medical insurance group that provides health services for a fixed annual fee. A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. examples: group model, individual practice association (IPA), network model, and staff model.

Question 58

ACO- Accountable Care Organization

Answer 58

groups of doctors, hospitals, and other healthcare providers, who come together voluntarily to give coordinated high-quality care to the Medicare patients they serve. ensure that pateints are receiving the right care at the right costs

Question 59

GDP- Gross Domestic Product

Answer 59

A comprehensive measure of U.S. economic activity. GDP measures the value of the final goods and services produced in the United States (without double counting the intermediate goods and services used up to produce them).

Question 60

Health care costs

Answer 60

the costs of healthcare

Question 61

Health care outcomes

Answer 61

the outcome of healthcare Outcomes are defined as the impact of a healthcare service or intervention, and can include events or results in: Patient health status or quality of life. Patient, provider, and population attitudes and behavior. New evidence, research, prevention strategies, treatments, and care models.

Question 62

Per capita

Answer 62

for each person; in relation to people taken individually. Per capita is a Latin phrase literally meaning "by heads" or "for each head", and idiomatically used to mean "per person". The term is used in a wide variety of social sciences and statistical research contexts, including government statistics, economic indicators, and built environment studies.

Question 63

Financing

Answer 63

provide funding for (a person or enterprise).

Question 64

Payment

Answer 64

the exchange of money, goods, or services for goods and services in an acceptable amount to both parties and has been agreed upon in advance.

Question 65

Employment-based health insurance

Answer 65

a health policy selected and purchased by your employer and offered to eligible employees and their dependents. These are also called group plans.

Question 66

Inflation

Answer 66

a loss of purchasing power over time, meaning your dollar will not go as far tomorrow as it did today. It is typically expressed as the annual change in prices for everyday goods and services such as food, furniture, apparel, transportation and toys.

Question 67

Cost control

Answer 67

the practice of identifying and reducing business expenses to increase profits, and it starts with the budgeting process. Cost control is an important factor in maintaining and growing profitability.

Question 68

Price control

Answer 68

government regulations on wages or prices or their rates of change. Governments can impose such regulations on a broad range of goods and services or, more commonly, on a market for a single good.

Question 69

Reference pricing

Answer 69

that price which users compare with the price of a competitor's product or the previously advertised price. Here the price of the product, which is more expensive, becomes the reference price for your product.

Question 70

Price transparency - public disclosure of prices what does it help consumers know? what did group health plan start doing

Answer 70

helps consumers know the cost of a covered item or service before receiving care. As of July 1, 2022, most group health plans and issuers of group or individual health insurance are posting pricing information for covered items and services.

Question 71

Cost shifting

Answer 71

a situation where one group of payers overpays costs for a good or service for another group, which in total pays less than the first one. if one payer (Medicare, say) pays less relative to costs, another (a private insurer, say) will necessarily pay more.

Question 72

Fee-for-service

Answer 72

MassHealth pays providers directly for each covered service received by an eligible MassHealth member. a payment model in which doctors, hospitals, and medical practices charge separately for each service they perform.

Question 73

Patient churning - high volumes of brief patient visits

Answer 73

the percentage of patients who leave your care

Question 74

Capitation

Answer 74

a fixed amount of money per patient per unit of time paid in advance to the physician for the delivery of health care services. is a payment arrangement for health care service providers. It pays a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care.

Question 75

Cost sharing (at point of service)

Answer 75

The share of costs covered by your insurance that you pay out of your own pocket

Question 76

Utilization management

Answer 76

the practice of evaluating and monitoring the use of healthcare services to assess their appropriateness and quality.

Question 77

Supply limits

Answer 77

maximum number of units that can ever be in circulation, and once the maximum supply is reached, no new units will be mined or issued.

Question 78

Supplier-induced-demand

Answer 78

happens when a provider of an item or service stimulates or produces more demand for their offering than would otherwise exist in the market.

Question 79

inital coverage level

Answer 79

After you meet your deductible, your plan will help pay for your covered prescription drugs. Your plan will pay some of the cost, and you will pay a copayment or coinsurance. How long you stay in the initial coverage period depends on your drug costs and your plan’s benefit structure. For most plans in 2023, the initial coverage period ends after you have accumulated $4,660 in total drug costs. Note: Total drug costs include the amount you and your plan have paid for your covered drugs.

Question 80

coverage gap or donut hole

Answer 80

This means there's a temporary limit on what the drug plan will cover for drugs. Not everyone will enter the coverage gap. The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs.

Question 81

catastrophe coverage

Answer 81

once your out-of-pocket spending reaches $7,400, you'll automatically get “catastrophic coverage.” Generally, this means you'll only pay a small coinsurance percentage (no more than 5%) or copayment for your covered Part D drugs for the rest of the calendar year.

Question 82

Why should pharmacists care about costs?

Answer 82

The price increase associated with more than 50% of Medicare Part D drugs outpaced inflation Abandonment rates are about 35% when the cost of medication is over $75; 45% when over $125 Medication non-adherence is associated with increased Hospitalizations ER visits Mortality Poor health outcomes (Cubanski, DeVila, IQVIA)

Question 83

Understanding Formularies tiers Tiering Exception

Answer 83

Formulary List of medications covered by an individual prescription plan based upon current evidence-based medicine Tier Pricing tier 1: generic meds tier 2: preferred brand medications tier 3: non-preferred meds tier 4 & 5: specialty meds Tiering Exception A way to lower cost-sharing by showing medications in lower tiers are ineffective or dangerous

Question 84

Formulary Considerations Prior Authorization Quantity Limits Step Therapy

Answer 84

Medication coverage restrictions seen on formularies *Information from the prescriber to the insurance plan stating the therapeutic need for the medication is required *Beneficiaries receive medications that are safe, effective and provide greatest value *Restricted to a maximum dose allowed to be dispensed in a given time frame *Beneficiaries are encouraged to use FDA-approved durations and dosages *Information from the prescriber to the insurance plan showing the patient has failed on other medications before given approval for prescribed medication *Beneficiaries are encouraged to use well established, cost-effective first-line medications

Question 85

Case Study: JS

Answer 85

JS is a 55-year-old female with Harvard Pilgrim Health Care insurance offered through her employer. She has recently been diagnosed with irregular heart rate (AFib or Atrial Fibrillation). She is currently taking Pradaxa 150 mg BID (dabigatran etexilate mesylate) and is concerned with the price of her medication ($50 each month) as she is beginning to feel she does not even have insurance. She asks you what can she do?

Question 86

Case Study: JS

Answer 86

Pradaxa is Tier 4: $50/month Alternative medication? Tier 1 (warfarin) medication: $5/month or $15/3 months through mail order Tier 3 (Eliquis) medication: $30/month or $90/3 months through mail order Work with healthcare prescriber to have medication switched

Question 87

benefits to add to medicare part D

Answer 87

extra help/low income subsidy medicaid State Pharmaceutical Assistance Program

Question 88

Extra Help/Low Income Subsidy

Answer 88

Federal program available in every state Helps with cost of Medicare Part D plan premium, deductible, copayments Eligibility guidelines 1 person: $1,843 monthly income/$16,660 assets 2 people: $2,485 monthly income/$32,240 assets

Question 89

Extra Help Benefit Categories full extra help partial extra help *don't have to know too well*

Answer 89

Monthly Income Limit Asset Limit Costs $1,660 individual $2,239 couple $10,590 individual $16,630 couple Copayments: no more than $4.15/$10.35 Deductible: none Premium: $0 options partial extra help: $1,843 individual $2,485 couple $16,660 individual $32,2400 couple Copayments: 15% up to threshold, then $4.15/$10.35 Deductible: $104 Premium: Reduced

Question 90

Medicaid

Answer 90

State-sponsored health and prescription benefit programs Referred to as dual eligible when added to Medicare Many different coverage types depending on age and status Eligibility guidelines vary according to income and status Helps with copayments, premiums, and deductibles of covered Medicare Part D medications

Question 91

State Pharmaceutical Assistance Program who administers this program? who is it for and what does it help them with what does it supplement and does it vary from state to state

Answer 91

State-administered programs that assist low-income older adults and individuals with disabilities in paying for prescriptions Supplements Medicare Part D coverage but varies from state to state Learn more about state programs at https://www.medicare.gov/pharmaceutical-assistance-program/state-programs.aspx Prescription Advantage in Massachusetts Secondary payer to Medicare Part D for most individuals Fills in the coverage gap (“donut hole”) Free for most people Enroll by calling 1-800-243-4636 New Hampshire AIDS Drug Assistance Program Diagnosis of AIDS or HIV Income tested Enroll by calling 603-271-4502

Question 92

Case Study: EM

Answer 92

EM is a 65-year-old Medicare beneficiary. He contacts the Pharmacy Outreach Program. He is wondering what programs can help him with the cost of his Eliquis in the Medicare Part D donut hole. He recently applied for Medicaid and was denied. Problem: cannot afford medication in the coverage gap

Question 93

What Do We Know About EM?

Answer 93

Current Part D plan Express Scripts Medicare-Saver (PDP) Household size: 1 Monthly income: $1,500 Assets are $8,500 Pharmacy is CVS

Question 94

What Can We Do To Help EM?

Answer 94

MassHealth No Already determined Extra Help Yes Under the income and asset limits EM’s monthly income: $1,500, Full Extra Help limit: $1,660/month EM’s assets: $8,500, Full Extra Help limit: $10,590 assets

Question 95

Private Assistance Options

Answer 95

patient assistance program copayment foundation special generic drug pricing program Rx coupons non-profit mail order pharmacy other option s

Question 96

Where To Search For Assistance Programs?

Answer 96

NeedyMeds is a non-profit information resource dedicated to helping people locate assistance programs to help them afford their medications and other healthcare costs Locate programs to help with medication cost

Question 97

Patient Assistance Programs

Answer 97

Pharmaceutical Manufacturer Programs Provides free or low-cost brand-name medication to eligible individuals Short-term, but can reapply each year Usually shipped to the patient or health care provider Helps uninsured or underinsured Eligibility guidelines vary – typically up to 250% of FPL

Question 98

Co-payment Foundations are you automatically enrolled every year? what are these organizations and what do they help with what is it specific to what must the medication be what can be said about income when are grants typically awarded

Answer 98

Charitable organizations that may help pay for certain prescription co-payments, deductibles, and plan premiums. Medication and Diagnosis Specific Medication must be a covered drug w/current insurance Income guidelines vary – some as high as 500% of the FPL Grants are typically awarded on an annual basis Re-application is required each year

Question 99

Special Generic Pricing Programs

Answer 99

Low Cost Generic Medications Offered by many retail pharmacies Some pharmacies offer certain medications free Available to anyone Any income Any age Insured or uninsured Not insurance

Question 100

Special Generic Pricing

Answer 100

Low cost insulin at Wal-Mart Pharmacies ReliOn Novolin® - $24.88/vial. Novolin® R - Short acting Novolin® N - Intermediate acting Novolin® 70/30 - Insulin vials and pens $42.88 per box (5 pens) ReliOn Novolog ®– NEW $72.88/vial $85.88/box (5 pens)

Question 101

Prescription Drug Coupons

Answer 101

Free coupons For anyone to use Cannot be combined with insurance Does not discount insurance copayments Accepted at most pharmacies Prices available on their website Print, or save coupon to your smartphone

Question 102

Non-Profit Mail Order Pharmacy

Answer 102

Rx Outreach Program is a non-profit, charitable organization that provides low cost, generic medications via mail order. Over 600 medications available No enrollment fees No membership fees No shipping or handling charges Pay only the price for the medication Income Guidelines: $58,320 for one | $78,880 for two

Question 103

Co-pay Cards

Answer 103

Medication specific Offered by pharmaceutical companies for brand name medications Reduces a co-payment, or may pay 100% of co-payment For individuals with employer sponsored health insurance Medicare & Medicaid beneficiaries are not eligible

Question 104

Free Trial Offers

Answer 104

Offered by pharmaceutical companies Typically for new medications' Usually for anyone to use Not readily available Provided by physicians Available at some pharmacies

Question 105

Price Chopper Diabetes Advantedge Program

Answer 105

Free medication and low-cost supplies at Price Chopper grocery store pharmacy Not insurance Available to anyone

Question 106

Strategies to reduce cost

Answer 106

Consider generics Find alternative medications in drug class Substitute an OTC product if possible Identify a lower-cost formulation Consider cost of retail vs. mail order pharmacy Research Part B vs. Part D coverage Ask the prescriber to request a tier exception

Question 107

Conclusion of lecture on prescription access Private Assistance Options Formularies Federal and state benefits to add to Medicare Part D

Answer 107

Private Assistance Options Various options available through retail, mail order, pharmaceutical companies, and others to lower the cost of medications for individuals with Medicare, other insurance, or with no insurance Formularies Medications arranged by tier levels with corresponding copayments/coinsurance Insurance companies may limit access to medications by using restrictions like prior authorizations, quantity limits, step therapy Health care providers can impact cost by prescribing medications in lower tier levels Federal and state benefits to add to Medicare Part D Social Security Extra Help, Medicaid, and State Pharmaceutical Assistance Programs are programs that can help with the cost of Medicare Part D premiums, deductibles, and/or copayments

Question 108

State Pharmaceutical Assistance Program

Answer 108

SPAPs are state-run programs that provide financial assistance to certain populations to help pay for prescriptions, though coverage varies widely by state, usage and specificity.

Question 109

Formulary

Answer 109

an official list giving details of medicines that may be prescribed.

Question 110

Prior Authorization

Answer 110

Approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan

Question 111

quantity limits

Answer 111

a restriction used by Part D plans and Medicare Advantage Plans. It limits coverage of a drug to a certain amount over a certain period of time, such as 30 pills per month.

Question 112

Step Therapy

Answer 112

If a health plan uses step therapy for certain drugs, it means that a patient can be required to try a lower cost prescription drug that treats a given condition before “stepping up” to a similar-acting, but more expensive drug.

Question 113

go through class medicare plan finder and see if you are okay with it!

Answer 113

okay! God is good

Question 114

What is the Quality of Healthcare?

Answer 114

Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge How care is provided should reflect appropriate use of the most current knowledge about scientific, clinical, technical, interpersonal, manual, cognitive, and organization and management elements of health care.”

Question 115

Why is Quality Important?

Answer 115

IOM’s “To Err Is Human: Building a Safer Health System” 44,000 deaths/yr in US from medical errors Total national costs $17-29 billion IOM’s “The Urgent Need to Improve Health Care Quality” Categorized 3 quality defects IOM’s “Crossing the Quality Chasm: A New Health System for the 21st Century” Identified 6 quality aims

Question 116

Quality of Healthcare

Answer 116

Despite improvements in quality, disparities still exist Disproportionally impact minorities and low-income populations 250,000 patients die each year from preventable medical errors 1 out of 25 will develop a hospital-acquired infection Hospitalized Medicare patients have a 1 in 4 chance of experiencing injury, harm, or death Variation in performance (high quality versus low-quality hospitals) Ambulatory care issues including preventative care

Question 117

Quality Defects underuse overuse misuse

Answer 117

Underuse Evidence based practices are not used as often as they should be ex: Ex: Neglecting mammograms for breast cancer screening Overuse Evidence based practices are used more frequently than the evidence supports ex: Ex: Prescribing antibiotics for viral infections Misuse Processes or products are not used correctly Ex: IM injection given IV

Question 118

Quality Aims Safe: Effective Efficient Timely Patient-centered Equitable

Answer 118

Safe: keep patients safe while caring for them Effective: develop evidence based practices to serve as standards for care Efficient: develop evidence based practices to serve as standards for care Timely: – avoid waits and delays for patients Patient-centered: - care should revolve around patient, considering their preferences and giving the patient a say in their care Equitable: get rid of disparities in healthcare – avoid unequal treatment

Question 119

Components of High Quality Healthcare A A C S O

Answer 119

Access; - a patient living in rural Ohio does not have access to a local dermatologist and cannot be seen for an annual skin check therefore skin cancer can not be diagnosed at an early stage. Adequate scientific knowledge: Which drugs to use effectively and the dosing; patient started with estrogen therapy and later being diagnosed with ovarian cancer Doing something and not knowing enough scientifically about it and so you do it wrong Competent providers: Not having provider with adequate training and they are misdiagnosed or undiagnosed with a patient Separation of financial and clinical decisions: Financial incentive to do a ertain procedure and doing surgery that is unnecessary—surgeon says “they do not need the surgery, but I will get more $ if I do it so I will do it” Decrease referrals to the ER– presciber gets more $ if they not refer to the ER Organization of healthcare institutions to maximize quality: Go to ER and inadequate staffing and do not get access to care due to low staffing—staffing is a constraint of quality because it leads to delays and not everyone is cared for

Question 120

Quality Organizations PQA AHRQ JCO NCQA IOM USP NQF

Answer 120

PQA = Pharmacy Quality Alliance AHRQ = Agency for Healthcare Research and Quality JCO = The Joint Commission NCQA = National Committee for Quality Assurance IOM = Institute of Medicine USP = United States Pharmacopeia NQF = National Quality Forum just need to be able to recognize names: JCO, USP & NQF

Question 121

Types of Measures- SPO

Answer 121

Structure Information about staffing, capacity, and volume; MEASURMENETS RELATED TO THOSE, how many pharmacist are staffing this day, how many are staffing in reference to prescription volume, what is the workflow and is it being done correctly Process Procedures that are followed when providing patient care; care like patients coming in and how many are getting screened for cancer—are those processes. Being done, what is the turning rate of bedside and what is recommended clinically, or prescribing rate. Are you doing things that needs to be done for certain patients. Surgery Outcome Endpoints or outputs of healthcare; what are the measures, infections post surgical outcome, adverse effects, BP DM goals

Question 122

Quality Improvement Shift

Answer 122

Newer Systems and Standards Computerized information systems Public reporting of quality Pay for reporting Pay for performance Financially neutral clinical decision-making Just culture concepts practice guidelines measuring practice patterns

Question 123

Just Culture and Quality

Answer 123

Now we prefer to use the just culture concept Sanctioning “bad apples” is only appropriate for reckless behavior in a just culture

Question 124

Clinical Practice Guidelines

Answer 124

Help ensure providers have easy access to the latest evidence Over 2,700 guidelines exist Limitations Must consider patient specific factors and preferences Must use clinical judgement

Question 125

Measuring Practice Patterns

Answer 125

Monitoring of process and outcome measures within a group or healthcare system Useful to track measures over time and among groups Prefer to use measure to build a better system or process rather than identify bad apples Root cause analysis (RCA) Why or where and error occurred

Question 126

New Systems and Standards

Answer 126

Computerized information systems Public reporting of quality Pay for reporting Pay for performance Financially neutral clinical decision making Value based measures

Question 127

Pharmacist’s Role in Promoting Quality Healthcare Focus on the Patient Keep Learning Promote Quality Culture

Answer 127

Focus on the Patient - Access to Care - Health Literacy - Cultural Competency Keep Learning - Continuing Education - Clinical Practice Guidelines Promote Quality Culture - Quality Measures - Quality Improvement - Just Culture

Question 128

Pharmacists Growing Role

Answer 128

Development of integrated virtual care teams Pharmacists as the most accessible healthcare professional Potential to contribute to safe and appropriate medication use quality measures Need to reallocate resources to improve adherence Provide services (immunization) Increase interaction with prescribers Value-based networks Move from volume to value Platforms between pharmacies and payers evaluating data to show that value is being provided no need to know just know that you are needed

Question 129

How do we know if we have achieved high quality healthcare?

Answer 129

we measure!

Question 130

lecture 2 objectives Recognize the flow of dollars in the US Healthcare system Define the different methods of controlling cost Identify scenarios where various methods of cost control have been implemented Analyze the limitations and potential negative impacts of cost control

Answer 130

Recognize the flow of dollars in the US Healthcare system - taxpayers & employers pay a premium (or financing; includes financing controls) to the health plan - health plan pays (includes payment controls) providers - The most important impact is with payment! - providers influence patient behavior and can cause patients to come back Define the different methods of controlling cost - Overuse or inappropriate utilization - Inefficient payment systems - High prices - Excessive administrative cost - Medical liability - Declining health status in the population / chronic disease Identify scenarios where various methods of cost control have been implemented - Regulatory Strategies - Competitive Strategies - Price controls - Utilization Controls - Patient Cost Sharing - Utilization Management - Supply limits Analyze the limitations and potential negative impacts of cost control - Cost shifting – Increasing charges to other payers to compensate for lowering the cost for one payer ---Problem often avoided using uniform fee schedules or single-payers - Patient churning - Inducing higher use of services (more visits/procedures/etc) to offset the lower price with higher volume in order to maintain earnings ----------Example: Medicaid fee-for-service pays physicians far below private insurance rates -Difficult for patients to find providers who will accept Medicaid -Results in patient churning, reduced quality of care, reduced patient satisfaction

Question 131

Which of the following immunizations are covered under Medicare Part D? choose all that apply A. Shingrix (Shingles vaccine) B. Flu C. Tetanus (prevention) D. Pneumonia E. Hepatitis B (low risk)

Answer 131

A. Shingrix (Shingles vaccine) C. Tetanus (prevention) notice not injury related, that would be part B E. Hepatitis B (low risk)

Question 132

the patient will be automatically enrolled in the Co-payment foundation program annually. A. True B. False

Answer 132

B. False They have to enroll themselves

Question 133

Medications listed on a plan's formulary are priced according to drug class, not tier level A. True B. False

Answer 133

B. False they are!

Question 134

hat services does Medicare Part B cover? (Select all that apply) A. Ambulance services B. Durable medical equipment C. Diabetic testing supplies D. Lab work E. Syringes associated with the injection of insulin

Answer 134

A. Ambulance services B. Durable medical equipment C. Diabetic testing supplies D. Lab work all things outpatient!

Question 135

Which of the following immunizations are covered under Medicare Part B? (Select all that apply) A. Flu B. Tetanus (prevention) C. Pneumonia D. Hepatitis B (High or intermediate risk) E. Shingles

Answer 135

A. Flu C. Pneumonia D. Hepatitis B (High or intermediate risk)

Question 136

What services does Medicare Part A cover? (Select all that apply) A. Outpatient services B. Outpatient mental healthcare C. Hospital care D. Skilled nursing facility care E. Home health-care services

Answer 136

C. Hospital care D. Skilled nursing facility care E. Home health-care services all inpatient services!

Question 137

The protected therapeutic categories that must be covered under Medicare Part D include (select all that apply): A. Diabetes B. Immunosuppressants C. Antihypertensive D. Anticonvulsant E. HIV/AIDs

Answer 137

B. Immunosuppressants D. Anticonvulsant E. HIV/AIDs

Question 138

Medicare Part D insurance coverage for individual medications and immunizations is provided through A. Federal Government B. State Government C. Private insurance companies D. Board of Pharmacy E. none of the above

Answer 138

C. Private insurance companies

Question 139

Patient Assistance Program provided by pharmaceutical manufacturers A. Are insurance programs that provide long-term coverage for many brand name medications B. Assist on generic medications C. Provide coverage for individuals who are uninsured or underinsured D. Both A and C E. All of the above

Answer 139

C. Provide coverage for individuals who are uninsured or underinsured

Question 140

which of the following medications/drug classes are not covered by Medicare Part D? (Select all that apply) A. Antipsychotics B. Immunosuppressants C. Weight management medications D. Over-the-counter medications E. Cosmetic and lifestyle drugs

Answer 140

C. Weight management medications D. Over-the-counter medications E. Cosmetic and lifestyle drugs

Question 141

which part of Medicare offers gym membership

Answer 141

C!

Question 142

where do you find Rx coupons?

Answer 142

goodRx.com