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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.
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Managed care organization types
- fee for service
- health maintenance organizations
- preferred payer organizations
- point of service
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Risk bearing
amount of risk borne by the providers
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physician type
relationship between the managed care organization and the physicians
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relationship exclusivity
whether physicians provide care to patient sfrom one managed care organization or to patient from multiple managed care organizations
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out of network coverage
wheter care received from a provider who is not in managed care organizatin's network is a covered benefit
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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
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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
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HMO types
- staff model
- group model
- network model
- independent practive association model
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Staff model HMO
directly empoys its physicians
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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
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Network model HMO
non-exclusive contracts with large medical groups
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independent practice association model HMO
non-exclusive contracts with solo or small physician groups
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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
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Differentiating features of PPOs
- providers bear no risk
- less restrictive
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Exclusive provider organizations (EPOs)
- type of PPO
- no coverage outside provider network
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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
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Do physicians bear risk in a staff HMO?
no
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Do physicians bear risk in a group HMO?
yes
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Do physicians bear risk in a network HMO?
yes
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Do physicians bear risk in a IPA HMO?
yes
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Do physicians bear risk in a PPO?
no
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Physicians bear risk in a EPO?
no
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Do physicians bear risk in a POS?
varies
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Physicain type in a staff HMO
staff
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Physicain type in a group HMO
large group
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Physicain type in a network HMO
several large groups with no exclusivity
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Physicain type in a IPA HMO
solo or small group
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Physicain type in a PPO
solo or group
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Physicain type in a EPO
solo or group
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Physicain type in a POS
varies
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Exclusivity of ralationship with physician in staff HMO
yes
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Exclusivity of ralationship with physician in group HMO
yes
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Exclusivity of ralationship with physician in Network HMO
no
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Exclusivity of ralationship with physician in IPA HMO
no
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Exclusivity of ralationship with physician in PPO
no
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Exclusivity of ralationship with physician in EPO
no
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Exclusivity of ralationship with physician in POS
varies
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Out of network coverage for staff HMO?
no
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Out of network coverage for group HMO?
no
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Out of network coverage for network HMO?
no
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Out of network coverage for IPA HMO?
no
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Out of network coverage for PPO?
yes
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Out of network coverage for EPO?
no
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Out of network coverage for POS?
yes
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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)
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Pharmacy benefits
- small portion of overal healthcare costs
- pharmacies do not bear risk
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Unit costs
- cost to fill a prescription
- medication cost + dispensing fee
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utilization rates
usually calculated over a year
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administrative costs
costs of processing a rx claim
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Pharmacy benefit managers
- manage pharmaceutical benefits for managed care organizations, medical providers or employers
- pharmacy networks
- lower costs
- online ajudication of claims
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Contract pricing is the lowest of the following
- contract rate
- maximum allowable cost
- usual and customary price
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contract rate
- percentage of average wholesale price with a dispensing fee
- looks at brand prices
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Maximum allowable cost
looks at generic prices with a dispensing fee
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usual and customary price
cash price
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Rebates
discount given to PBM by manufacturer based on formulary decisions
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The primary purpose of a formulary is to encourage...
the use of safe, effective and most affordable medications
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open formularies
everything is covered
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closed formularies
not on formulary is not covered
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incented formularies
step or tiered formularies
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Formulary managements
- PAs
- step therapies
- quantity limits
- refill limits
- generic substitution
- therapeutic interchange
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Mail service pharmacies can negotiate discounts on product costs due to...
large prescription volumes
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incentives for using the mail service pharmacy
discounted copays
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soft edit overrides
pharmacist inputs code to override
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hard edit overrides
pharmacy must contact PBM for code to override
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Drug utilization review
- review use of drugs
- ensure appropriate medication use
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Prospective DUR
conducted at the time the rx is dispensed
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retrospective DUR
primary goal is to educate PBM to see which physicains aren't prescribing medications appropriately
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Cost minimization outcomes goal
identical
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cost effectiveness
- natural units
- different amounts
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Formulary Dossier
- Drug compay prepares
- report on drug product
- used for P&T committees
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Sections of a Dossier
- Product information
- supporting clinical and economic information
- economic value
- other
- references
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Product information section of a dossier
description and place in therapy
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Supporting clinical and economic information in a dossier
- published and unpublished
- efficafcy and effectiveness trials
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economic value and modeling report in a dossier
summary of clinical and economic impact as it pertains to the MCO
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Other section of a dossier includes
off label info
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Warnings about dossiers
- may contain bias
- model transparency
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Drug monographs
- prepared by health system or MCO
- detailed report on drug product
- similar sections as a dossier
- data tailored to organization
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Absolute risk reduction
- control-experiment
- used when outcomes are statistically significantly different
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relative risk reduction
- control-experiment / control
- can be misleading
- commonly presented in clinical trials
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Number needed to treat
1/ARR
1/2% = 50 patients treated to prevent 1 death
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Number needed to harm
- 1/ARI
- only used when adverse event is significantly higher in one group vs. the other
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Reasons to utilize a budget impact model
- predict budgets for upcomming years
- analyze impact of a new treatment
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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)
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Per memeber per month calculation
(total cost/number of members)/number of months
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