Econ Exam 3

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Rx2013
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52877
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Econ Exam 3
Updated:
2010-12-02 12:51:29
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Managed Health Care Overview
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Managed Health Care Overview
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  1. Who is managed care?
    body of clinical, financial and organizational activities designed to ensure provision of appropriate health care services in a cost efficient manor.
  2. Managed care organization types
    • fee for service
    • health maintenance organizations
    • preferred payer organizations
    • point of service
  3. Risk bearing
    amount of risk borne by the providers
  4. physician type
    relationship between the managed care organization and the physicians
  5. relationship exclusivity
    whether physicians provide care to patient sfrom one managed care organization or to patient from multiple managed care organizations
  6. out of network coverage
    wheter care received from a provider who is not in managed care organizatin's network is a covered benefit
  7. Fee for service plans
    • usually more expensive and no preventative care
    • either pays provider directly or reimburses pt
    • no provider networks
    • patient can chose doc or hospital of thier choice
  8. Health maintenance organizations
    • places providers at risk (except staff model)
    • generally no coverage provided for out of network care
    • Gatekeeper (physician)
    • physician recieves pmt per year per patient
    • member pays less since it is more restrictive
  9. HMO types
    • staff model
    • group model
    • network model
    • independent practive association model
  10. Staff model HMO
    directly empoys its physicians
  11. Group Model HMO
    • contracts exclusivily with large medical group
    • physician group is payed a lump sum per year for a patient then that money is divided between the physicians that provided the care
  12. Network model HMO
    non-exclusive contracts with large medical groups
  13. independent practice association model HMO
    non-exclusive contracts with solo or small physician groups
  14. Preferred Provider Organizations
    • affiliations of providers that seek contracts with insurance plans
    • members have financial incentives to see in-network providers
    • Discounted FFS pmt to physicians
    • no gate keeper or PCP, or referals
  15. Differentiating features of PPOs
    • providers bear no risk
    • less restrictive
  16. Exclusive provider organizations (EPOs)
    • type of PPO
    • no coverage outside provider network
  17. Point of service plan
    • hybrid or open-ended HMO
    • allow pt to select provider when service is needed
    • physician not contracted w/ HMO paid according to service provided
    • only partial coverage is paid for physicains outside preferred network
  18. Do physicians bear risk in a staff HMO?
    no
  19. Do physicians bear risk in a group HMO?
    yes
  20. Do physicians bear risk in a network HMO?
    yes
  21. Do physicians bear risk in a IPA HMO?
    yes
  22. Do physicians bear risk in a PPO?
    no
  23. Physicians bear risk in a EPO?
    no
  24. Do physicians bear risk in a POS?
    varies
  25. Physicain type in a staff HMO
    staff
  26. Physicain type in a group HMO
    large group
  27. Physicain type in a network HMO
    several large groups with no exclusivity
  28. Physicain type in a IPA HMO
    solo or small group
  29. Physicain type in a PPO
    solo or group
  30. Physicain type in a EPO
    solo or group
  31. Physicain type in a POS
    varies
  32. Exclusivity of ralationship with physician in staff HMO
    yes
  33. Exclusivity of ralationship with physician in group HMO
    yes
  34. Exclusivity of ralationship with physician in Network HMO
    no
  35. Exclusivity of ralationship with physician in IPA HMO
    no
  36. Exclusivity of ralationship with physician in PPO
    no
  37. Exclusivity of ralationship with physician in EPO
    no
  38. Exclusivity of ralationship with physician in POS
    varies
  39. Out of network coverage for staff HMO?
    no
  40. Out of network coverage for group HMO?
    no
  41. Out of network coverage for network HMO?
    no
  42. Out of network coverage for IPA HMO?
    no
  43. Out of network coverage for PPO?
    yes
  44. Out of network coverage for EPO?
    no
  45. Out of network coverage for POS?
    yes
  46. Importance of Managed Care Organizations
    • assume financial risk
    • advocate for improving patient care
    • help control healthcare costs
    • encourage continuity of care
    • better oversight of patient care (entire patient picture)
  47. Pharmacy benefits
    • small portion of overal healthcare costs
    • pharmacies do not bear risk
  48. Unit costs
    • cost to fill a prescription
    • medication cost + dispensing fee
  49. utilization rates
    usually calculated over a year
  50. administrative costs
    costs of processing a rx claim
  51. Pharmacy benefit managers
    • manage pharmaceutical benefits for managed care organizations, medical providers or employers
    • pharmacy networks
    • lower costs
    • online ajudication of claims
  52. Contract pricing is the lowest of the following
    • contract rate
    • maximum allowable cost
    • usual and customary price
  53. contract rate
    • percentage of average wholesale price with a dispensing fee
    • looks at brand prices
  54. Maximum allowable cost
    looks at generic prices with a dispensing fee
  55. usual and customary price
    cash price
  56. Rebates
    discount given to PBM by manufacturer based on formulary decisions
  57. The primary purpose of a formulary is to encourage...
    the use of safe, effective and most affordable medications
  58. Types of formularies
    • open
    • closed
    • incented
  59. open formularies
    everything is covered
  60. closed formularies
    not on formulary is not covered
  61. incented formularies
    step or tiered formularies
  62. Formulary managements
    • PAs
    • step therapies
    • quantity limits
    • refill limits
    • generic substitution
    • therapeutic interchange
  63. Mail service pharmacies can negotiate discounts on product costs due to...
    large prescription volumes
  64. incentives for using the mail service pharmacy
    discounted copays
  65. soft edit overrides
    pharmacist inputs code to override
  66. hard edit overrides
    pharmacy must contact PBM for code to override
  67. Drug utilization review
    • review use of drugs
    • ensure appropriate medication use
  68. Two types of DUR
    • prospective
    • retrospecitve
  69. Prospective DUR
    conducted at the time the rx is dispensed
  70. retrospective DUR
    primary goal is to educate PBM to see which physicains aren't prescribing medications appropriately
  71. Value =
    quality/cost
  72. Cost minimization outcomes goal
    identical
  73. cost effectiveness
    • natural units
    • different amounts
  74. cost utility
    QALYs
  75. Cost benefit
    $
  76. Formulary Dossier
    • Drug compay prepares
    • report on drug product
    • used for P&T committees
  77. Sections of a Dossier
    • Product information
    • supporting clinical and economic information
    • economic value
    • other
    • references
  78. Product information section of a dossier
    description and place in therapy
  79. Supporting clinical and economic information in a dossier
    • published and unpublished
    • efficafcy and effectiveness trials
  80. economic value and modeling report in a dossier
    summary of clinical and economic impact as it pertains to the MCO
  81. Other section of a dossier includes
    off label info
  82. Warnings about dossiers
    • may contain bias
    • model transparency
  83. Drug monographs
    • prepared by health system or MCO
    • detailed report on drug product
    • similar sections as a dossier
    • data tailored to organization
  84. Absolute risk reduction
    • control-experiment
    • used when outcomes are statistically significantly different
  85. relative risk reduction
    • control-experiment / control
    • can be misleading
    • commonly presented in clinical trials
  86. Number needed to treat
    1/ARR

    1/2% = 50 patients treated to prevent 1 death
  87. Number needed to harm
    • 1/ARI
    • only used when adverse event is significantly higher in one group vs. the other
  88. Reasons to utilize a budget impact model
    • predict budgets for upcomming years
    • analyze impact of a new treatment
  89. Data needed for a budget impact model
    • population size and characteristics
    • costs of new treatment
    • cost of treatments the new treatment is replacing (if any)
  90. Per memeber per month calculation
    (total cost/number of members)/number of months

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