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Managed Care Overview
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Managed Care Overview

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@AttentiveEarth

Questions and Answers

What is the primary focus of drug utilization review (DUR) interventions?

  • Improving therapeutic outcomes (correct)
  • Increasing prescription volumes
  • Reducing patient visits
  • Enhancing drug marketing

    • What is the first step of the Five Steps of DUR?

  • Measure actual use of medications
  • Identify optimal drug use (correct)
  • Evaluate the effectiveness of the DUR process
  • Take action to correct discrepancies

    • What must be ensured about the confidentiality of patient relationships in DUR?

  • It can be shared with family members
  • It must be protected (correct)
  • It must be disregarded for efficiency
  • It is secondary to cost reduction

    • Which type of DUR is conducted before a medication is dispensed?

    <p>Prospective DUR</p> Signup and view all the answers

    What is a key part of the Five Steps of DUR that involves actual patient data?

    <p>Compare optimal and actual medication use</p> Signup and view all the answers

    What should criteria and standards for DUR be?

    <p>Nonproprietary and developed through consensus</p> Signup and view all the answers

    In DUR, what does 'taking action to correct discrepancies' involve?

    <p>Implementing necessary changes in therapy</p> Signup and view all the answers

    Which of the following statements is true regarding retrospective DUR?

    <p>It evaluates after the medication use has occurred.</p> Signup and view all the answers

    What does 'confidentiality of the relationship' refer to in DUR?

    <p>Protecting patient information from unauthorized access</p> Signup and view all the answers

    Why is measuring actual use of medications important in DUR?

    <p>To find discrepancies in prescribing patterns</p> Signup and view all the answers

    What is the primary goal of managed care organizations?

    <p>Control costs while improving health care quality</p> Signup and view all the answers

    Which type of managed care organization requires members to prepay a premium for medical services?

    <p>Health Maintenance Organization (HMO)</p> Signup and view all the answers

    What is the function of the Pharmacy & Therapeutics Committee?

    <p>To decide which drugs are included on a formulary</p> Signup and view all the answers

    What best describes a closed formulary?

    <p>A limited number of drugs are available and non-formulary drugs are non-covered</p> Signup and view all the answers

    What characterizes a partially/selectively closed formulary?

    <p>Similar to an open formulary, but with some selected drugs not covered</p> Signup and view all the answers

    Which managed care plan allows members to go out of network but with higher costs?

    <p>Point-of-Service (POS) Plan</p> Signup and view all the answers

    What does formulary management primarily focus on?

    <p>Selecting the most effective and cost-effective drug therapies</p> Signup and view all the answers

    What is the purpose of drug utilization review?

    <p>To monitor and analyze medication dispensing for quality control</p> Signup and view all the answers

    What is typically the co-payment amount for Tier 1 drugs?

    <p>$15</p> Signup and view all the answers

    Which of the following is NOT a type of managed care organization?

    <p>Health Savings Account (HSA)</p> Signup and view all the answers

    What type of managed care organization limits or does not cover out-of-network services?

    <p>Exclusive Provider Organization (EPO)</p> Signup and view all the answers

    What is one goal of managing a drug formulary?

    <p>To enhance the quality of care and assure appropriate drug therapy</p> Signup and view all the answers

    What defines the co-payment for Tier 4 drugs?

    <p>Highest fixed amount paid by the member</p> Signup and view all the answers

    The National Committee for Quality Assurance (NCQA) was formed to measure what aspect of managed care organizations?

    <p>Health plan performance through performance metrics</p> Signup and view all the answers

    What type of drugs are included in Tier 3 of the example formulary?

    <p>Non-preferred/non-formulary brand drugs</p> Signup and view all the answers

    What was established by the Social Security Act of 1965?

    <p>Medicare and Medicaid programs</p> Signup and view all the answers

    What will a systematic drug utilization review help to reduce?

    <p>The number of unnecessary medications prescribed</p> Signup and view all the answers

    Which feature is NOT found in a closed formulary?

    <p>Access to all medications without restrictions</p> Signup and view all the answers

    What form of payment is typically associated with Tier 2 drugs?

    <p>Intermediate fixed amount co-payment</p> Signup and view all the answers

    What is the primary goal of Disease State Management (DSM)?

    <p>Improve quality of life and reduce healthcare costs associated with chronic conditions</p> Signup and view all the answers

    What is a primary responsibility of pharmacists regarding medication verification?

    <p>To verify medication dosages and interactions</p> Signup and view all the answers

    Which analysis evaluates costs of interventions that are therapeutically equivalent?

    <p>Cost-minimization analysis</p> Signup and view all the answers

    What is one significant advantage of electronic prescribing (e-prescribing)?

    <p>Improved accuracy of prescriptions</p> Signup and view all the answers

    What does outcomes research primarily evaluate?

    <p>A treatment's clinical, economic, or humanistic results</p> Signup and view all the answers

    What is a common chronic condition managed under Disease State Management?

    <p>Diabetes mellitus</p> Signup and view all the answers

    Which component is part of pharmacoeconomic evaluation?

    <p>Cost-benefit analysis</p> Signup and view all the answers

    What is a key function of specialty pharmacies?

    <p>To address challenges associated with chronic disease states</p> Signup and view all the answers

    What technique does medication management in specialty pharmacies utilize?

    <p>Prior authorization and step-therapy</p> Signup and view all the answers

    What does cost-utility analysis specifically assess?

    <p>Patient's functional status or quality of life</p> Signup and view all the answers

    What is a key component of a Patient-Centered Medical Home (PCMH)?

    <p>Focus on whole person health</p> Signup and view all the answers

    What significant change does the Affordable Care Act (ACA) implement regarding coverage for young adults?

    <p>Enables children to remain on their parents' plan until age 26</p> Signup and view all the answers

    Which of the following is NOT a provision of the Affordable Care Act (ACA)?

    <p>Mandatory insurance for all ages starting at 18</p> Signup and view all the answers

    What is the primary focus of stakeholders in a managed care system?

    <p>Balancing cost with quality of care</p> Signup and view all the answers

    Which of the following describes the concept of coinsurance?

    <p>A percentage of costs that the patient pays after deductible</p> Signup and view all the answers

    Stakeholder involvement in healthcare typically includes which of the following?

    <p>Financial risk sharing among providers and health plans</p> Signup and view all the answers

    Study Notes

    Managed Care Overview

    • Managed care aims to deliver health care efficiently by reducing costs while improving quality and access to services.
    • Managed care pharmacy enhances medication effectiveness and overall patient health.

    Goals of Managed Care Organizations (MCOs)

    • Prevent disease and promote wellness.
    • Enhance medication therapy and control costs.
    • Make population-based decisions rather than individual-focused.

    Historical Background

    • MCOs evolved from prepaid health plans established in the early 1990s.
    • The Health Maintenance Organization (HMO) Act of 1973 facilitated HMO development with federal funding.

    Key Entities

    • National Committee for Quality Assurance (NCQA) measures health plan performance using standardized metrics (HEDIS).

    Types of Managed Care Organizations

    • Health Maintenance Organization (HMO): Members pay premiums for services from contracted providers. Subtypes include staff, group, network, and independent practice association models.
    • Preferred Provider Organization (PPO): Offers a network of providers but less control compared to HMOs.
    • Point-of-Service (POS): Members may choose out-of-network services at a higher cost, blending HMO and PPO features.
    • Exclusive Provider Organization (EPO): Coverage is limited to in-network providers.
    • Consumer Directed Health Plans (CDHP): Combine high deductible plans with health savings accounts for cost management.
    • Pharmacy Benefit Manager (PBM): Manages drug utilization on behalf of payers to control costs.

    Government Programs

    • Established by the Social Security Act of 1965, which created Medicare and Medicaid.
    • Medicare: Provides health coverage for individuals aged 65 and older. Includes four parts:
      • Part A: Hospital Insurance
      • Part B: Outpatient Medical Services
      • Part C: Medicare Advantage Plans
      • Part D: Prescription Drug Coverage

    Clinical Tools in Managed Care

    • Formulary Management: Lists covered medications to guide effective drug therapy, using evidence-based processes.
    • Pharmacy & Therapeutics (P&T) Committee: Evaluates and updates the formulary with healthcare professionals involved.
    • Drug Utilization Review (DUR): Ensures appropriate medication use, encompassing prospective, concurrent, and retrospective reviews.

    Disease State Management (DSM)

    • Aims to enhance quality of life and reduce health care costs by managing chronic diseases like diabetes and hypertension.

    Outcomes Research

    • Evaluates treatments based on clinical, economic, and humanistic outcomes, determining cost-effectiveness through various analyses such as cost-benefit analysis and cost-utility analysis.

    Current Directions in Managed Care

    • Electronic Prescribing: Increases accuracy and efficiency in prescribing medications, supported by federal incentives.
    • Specialty Pharmacy: Addresses complex medication management needs for chronic diseases, focusing on tailored patient support.
    • Patient-Centered Medical Homes (PCMH): Promote coordinated, collaborative care aimed at treating the whole person and engaging patients in their health decisions.
    • Affordable Care Act (ACA): Introduced significant reforms to healthcare insurance and system structures, enhancing consumer access and protections.

    Stakeholder Involvement

    • Stakeholders (healthcare providers, health plans, and members) share financial risks and aim for high-quality care.
    • Managed care's success relies on balancing cost control with quality service delivery.

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    Quiz Team

    Description

    This quiz covers essential concepts in managed care, including the types of managed care organizations and their goals. It will also explore formulary management, drug utilization reviews, and the role of Pharmacy & Therapeutics Committees. Students will gain insights into outcomes research and economic evaluations in the context of healthcare.

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