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Phar 738 > Week 7 > Flashcards

Week 7 Flashcards

1
Q

T/F a form of reimbursement method is fee for services (FFS)

A

True

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2
Q

Define the prospective payment system (ex. With Medicare)

A

Given a specific diagnosis requiring in-patient care, ins will only cover a set amount of days. Once you exceed those days Medicare no longer pays and the hospital has to cover the extra days

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3
Q

What is the reimbursement criterium for fee for service?

A

Per diagnosis
Per patient
Per year

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4
Q

What are three examples of programs that help measure quality of healthcare plans?

A

-Healthcare Effectiveness Data and Information Set (HEDIS)
-Consumer Assessment of Healthcare Providers and Systems (CAHPS)
Health Outcomes Survey (HOS)

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5
Q

What is the NCQA HEDIS Measure?

A

Report as part of the five star quality rating system for Medicare advantage plans
Measures the amount of women over age 67 getting bone mineral density tests performed or begin anti-osteoporosis therapy within 6 months of a fracture

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6
Q

What did CPOMS program do to help women over 65 who sustained a fracture?

A

Increased ability to receive treatment, (tests, medication) and improved patient use of post-fracture medication

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7
Q

When did Medicare advantage plan ratings become implemented?

What was its purpose?

A

2012

If scaled bonuses will lead to better quality improvements in Medicare advantage plans

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8
Q

What percentage of rebate do 5 star plans receive? Is the benchmark higher based on star rating? The rebate percentage is the difference between the _______ and _________

A

73%
Yes
Benchmark, plan bid

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9
Q

Which program implemented the star rating program?

A

CMS

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10
Q

The new benchmark percentage for a 5 star plan is the original benchmark plus what %?

A

5%

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11
Q

What is the rebate percentage for a 3 star plan?

A

67%

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12
Q

The new benchmark percentage for a 3 star plan is the original benchmark plus what %?

A

3%

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13
Q

What is the Accountable Care Organization (ACO)?

Is it rewarded for positive outcomes and penalized for negative outcomes?

A

Delivers care to patients and of receiving payments from insurers focused on primary care
Yes

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14
Q

What is the purpose of Oregon CCO Measures?

A

Determine if CCOs are effective at improving care, access to quality care, removing health disparities, and controlling costs

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15
Q

What does the Pharmacy Quality Alliance (PQA) do?

A

Use data to implement quality measures

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16
Q

T/F CMS has used PQA measures in star rating for Part B programs

A

False, part D programs

17
Q

What is the purpose of the CMS Readmissions Reduction Program?
How much can they reduce reimbursements?

A

Penalize hospitals for readmissions to incentivize adequate care to prevent readmissions within 30 days
Up to 3%

18
Q

Define transitions of care

A

Movement of a patient from one setting of care to another

19
Q

Define stick

A

Excessive readmission penalties

20
Q

Define carrot

A

Codes used identifying reimbursement for care management and care coordination

21
Q

What are ICD-10 codes used for?

A

Codes used to describe conditions

22
Q

What are CPT codes used for?

A

Describe procedures medical professionals do

23
Q

What provider service was implemented to prevent readmissions related to drugs?

A

Pharmacist spends 30 minutes with pt

24
Q

How did transitional care billing impact patients and hospitals?

A

Hospitals are able to bill properly to receive higher reimbursement from insurance thus reducing cost billed to patient

25
Q

What is the quadruple aim?

A
  • Improve population health
  • Reduce cost of care
  • Enhance patient experience
  • Improve care team well-being
26
Q

Define scope of practice

A

Everything a healthcare practitioner is permitted to do under their license

27
Q

Define provider status

A

Classification allowing a healthcare professional to be reimbursed for services allowed by scope of practice

28
Q

Define credentialing (provider)

A

Verification of experience and ability to provide care that allows a healthcare professional to be reimbursed

29
Q

T/F a pharmacist’s scope of practice is defined by the state they’re practicing in

A

True

30
Q

What was the House Bill 2397?
What was it composed of?
What is its purpose?

A

Formed the Public Health and Formulary Advisory Committee consisting of two physicians, two nurse practitioners, and three pharmacists

Makes recommendations to board of pharmacy to determine what pharmacists can prescribe and dispense

31
Q

What did the pharmacy and medically underserved areas enhancement act do?

A

Allow pharmacist services under Medicare part B be reimbursable in underserved populations

32
Q

T/F pharmacists are considered providers on a federal level

A

False

Phar 738 (8 decks)

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