Medicare and Pharmacoeconomics Quiz
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Questions and Answers

What was the primary purpose of establishing Medicare?

  • To provide healthcare benefits for citizens aged 65 years and older (correct)
  • To replace private insurance companies
  • To cover medical expenses for any age group
  • To provide insurance for all US citizens regardless of age

Which additional groups were covered under Medicare by 2001?

  • All retired individuals regardless of disability
  • Individuals over 75 years with chronic illnesses
  • Individuals under 65 with disabilities and those with ALS (correct)
  • Low-income families with children

What is the financing source for Medicare Part A?

  • 2.9% payroll tax from employers and employees (correct)
  • Out-of-pocket payments by beneficiaries
  • General revenues and private donations
  • State funding and additional appropriations

How long must individuals contribute payroll taxes to qualify for Medicare?

<p>At least 10 years (C)</p> Signup and view all the answers

Which Medicare part covers outpatient services and physician visits?

<p>Part B (A)</p> Signup and view all the answers

What is the deductible amount for Medicare Part A in 2024?

<p>$1,632.00 (D)</p> Signup and view all the answers

Which services are covered by Medicare Part A?

<p>Inpatient hospital services and hospice care (D)</p> Signup and view all the answers

What type of insurance is Medicare categorized under?

<p>Government-based insurance (B)</p> Signup and view all the answers

What is a common disadvantage of chemotherapy agents regarding their economic assessment?

<p>It is difficult to determine an accurate QALY value. (D)</p> Signup and view all the answers

In cost utility analysis (CUA), what is the outcome measurement unit?

<p>Quality-adjusted life year (QALY) (D)</p> Signup and view all the answers

What does cost effectiveness analysis (CEA) primarily measure?

<p>Natural units like life years gained or specific health measures. (B)</p> Signup and view all the answers

Which pharmacoeconomic analysis focuses exclusively on financial aspects without considering patient outcomes?

<p>Cost minimization analysis (CMA) (C)</p> Signup and view all the answers

Which of the following is NOT a characteristic of cost benefit analysis (CBA)?

<p>Outcomes are expressed in natural health metrics. (D)</p> Signup and view all the answers

What type of analysis involves assessing two chemotherapy regimens for non-small cell lung cancer?

<p>Cost effectiveness analysis (CEA) (D)</p> Signup and view all the answers

Which pharmacoeconomic study type is primarily concerned with the comparison of costs when outcomes are assumed equal?

<p>Cost minimization analysis (CMA) (C)</p> Signup and view all the answers

What is the primary unit of comparison within cost utility analysis?

<p>Quality-adjusted life years (QALY) (A)</p> Signup and view all the answers

What was the Medicare Advantage program created through?

<p>The Balanced Budget Act of 1997 (D)</p> Signup and view all the answers

What type of plans can administer Medicare Advantage?

<p>Managed care plans (A)</p> Signup and view all the answers

Which of the following is NOT a type of plan included in Medicare Advantage?

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

What does a Medicare Advantage plan include if it has Part D benefits?

<p>Medicare Advantage Prescription Drug Plan (D)</p> Signup and view all the answers

During which period can beneficiaries enroll in Part C services?

<p>Annual Open Enrollment period (A)</p> Signup and view all the answers

What role does the healthcare team play in outpatient clinics concerning Medicare?

<p>Determine covered drug options and steps for coverage (B)</p> Signup and view all the answers

For what purpose does a pharmacy utilize Medicare information?

<p>To bill the plan for prescription drug claims (C)</p> Signup and view all the answers

Which of the following is included in the comprehensive coverage of Medicare Advantage?

<p>Outpatient prescription drugs (A)</p> Signup and view all the answers

What is categorized as direct medical costs in pharmacoeconomic studies?

<p>Cost of medications and treatments (A)</p> Signup and view all the answers

Which type of cost relates to loss of productivity due to illness?

<p>Indirect costs (B)</p> Signup and view all the answers

What is the purpose of timing adjustments in pharmacoeconomic studies?

<p>To account for inflation and time value of money (C)</p> Signup and view all the answers

Which formula would you use to calculate the present value of costs?

<p>PV = Future value / (1 + discount rate)^number of years (D)</p> Signup and view all the answers

Which of the following is NOT a type of direct medical cost?

<p>Homecare services (A)</p> Signup and view all the answers

In pharmacoeconomics, what do intangible costs represent?

<p>Emotional or psychological impacts of a disease (D)</p> Signup and view all the answers

What is the main focus of pharmacoeconomics?

<p>Both costs and outcomes related to healthcare products (C)</p> Signup and view all the answers

What triggers a beneficiary to enter the catastrophic coverage phase in Medicare?

<p>When TROOP expenses reach a specific limit (C)</p> Signup and view all the answers

What does ACER stand for in pharmacoeconomic evaluations?

<p>Average Cost Effectiveness Ratio (B)</p> Signup and view all the answers

How many tiers of coverage are commonly found in Medicare PDP drug formularies?

<p>Four to seven tiers (B)</p> Signup and view all the answers

Which of the following costs are excluded from direct medical costs?

<p>Patient deductibles and copayments (B)</p> Signup and view all the answers

Aside from direct medical costs, which costs should researchers consider when evaluating the impact of treating patients with certain diseases?

<p>Housing costs (B)</p> Signup and view all the answers

Who is responsible for approving medications for inclusion in the drug formulary?

<p>Centers for Medicare &amp; Medicaid Services (CMS) (A)</p> Signup and view all the answers

What is the best perspective for pharmacoeconomic studies according to current economic theory?

<p>Societal costs (C)</p> Signup and view all the answers

What is the purpose of the Pharmacy & Therapeutics (P&T) Committee in Medicare?

<p>To include new medications on formularies (A)</p> Signup and view all the answers

When must the initial formulary draft be submitted to CMS?

<p>In the Spring months before the calendar year (A)</p> Signup and view all the answers

When estimating costs based on data collected more than one year prior or extending more than one year into the future, what should researchers do?

<p>Adjust costs to the present year (B)</p> Signup and view all the answers

What is the final decision period for the Pharmacy & Therapeutics Committee regarding new drugs?

<p>Within 180 days of market launch (C)</p> Signup and view all the answers

Which of the following best describes the most common perspective in pharmacoeconomic studies?

<p>Institution or payer costs (B)</p> Signup and view all the answers

What components are included in societal costs?

<p>Costs to insurance, patients, and productivity losses (A)</p> Signup and view all the answers

What must be done before the annual open enrollment period regarding the formulary?

<p>It must be finalized and approved (D)</p> Signup and view all the answers

Which of the following is an example of patient and family costs?

<p>Family's share of medical bills and non-medical expenses (B)</p> Signup and view all the answers

Which of the following best describes the structure of the most common Medicare PDP drug formulary?

<p>Five-tier plan (C)</p> Signup and view all the answers

Why are societal costs rarely used in pharmacoeconomic studies?

<p>They are too complicated to measure (B)</p> Signup and view all the answers

Flashcards

Pharmacoeconomic Costs

Calculated to estimate resources used in producing an outcome.

Direct Medical Costs

Costs directly related to medical care.

Direct Non-Medical Costs

Costs not related to direct medical care, but still related to healthcare.

Indirect Costs

Costs due to lost productivity (time off work).

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Intangible Costs

Costs related to pain, suffering, or quality of life.

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Pharmacoeconomic Study Perspective

The viewpoint (e.g., payer, patient) used to measure costs in the study

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Cost-Effectiveness Ratio (ACER)

Ratio of the cost to the outcome.

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Incremental Cost-Effectiveness Ratio (ICER)

Difference in costs between two treatments (alternative).

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Cost Minimization Analysis (CMA)

A type of pharmacoeconomic analysis that assumes outcomes are equivalent across treatment groups. Focuses on comparing costs.

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Cost Benefit Analysis (CBA)

A pharmacoeconomic analysis that measures both costs and benefits in monetary terms.

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Cost Effectiveness Analysis (CEA)

A pharmacoeconomic analysis that compares costs to outcomes expressed in natural units like life years gained or mmHg.

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Cost Utility Analysis (CUA)

A type of CEA that measures outcomes in quality-adjusted life years (QALYs) or other utility measures.

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Quality-Adjusted Life Year (QALY)

A measure of health outcome that combines length of life with quality of life.

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Pharmacoeconomic Study Types

Different approaches to evaluate the costs and outcomes of pharmaceutical treatments.

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Chemotherapy Regimen

A set of drugs used together to treat cancer.

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Non-Small Cell Lung Cancer

A common type of lung cancer that is not characterized by small-sized cells.

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Societal costs

Includes costs to insurance companies, patients, and indirect costs from lost productivity.

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Institution/Payer costs

Costs to a third-party payer (like insurance), patient co-pays, or a combination of both.

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Study perspective

Specifies whose costs are important in a pharmacoeconomic study.

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Timing adjustments for costs

Needed when cost data is collected from more than a year before or more than a year into the future.

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Other sector costs

Resources used in non-healthcare sectors potentially impacted by treatments or diseases.

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Patient and family costs

Costs paid by patients and families, regardless of medical vs. non-medical reasons.

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Medicare Part C

A Medicare advantage plan offered by private insurance companies. It combines parts A, B, and usually D into one plan.

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Perspective influences cost

The 'who' of the cost calculation affects what economic data is important to measure.

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Medicare Advantage

The private plan model for Part C Medicare, administered by insurance companies.

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Retrospective data adjustment

Adjusting costs from data collected in the past, to the present day.

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Managed Care Plans

Private insurance plans providing Part C Medicare Advantage. (e.g., HMOs, PPOs, PFFS, SNPs).

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HMO (Health Maintenance Organization)

A type of managed care plan that requires members to use doctors and hospitals within their network.

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Part D Prescription Drug Plans

Prescription drug coverage for Medicare beneficiaries. Often a part of Medicare Advantage.

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Open Enrollment

A specific time period when beneficiaries can enroll, switch or change their Medicare Part C options.

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Patient's Pharmacy

Pharmacy utilized by the patient to fill and manage prescription drugs under a covered plan.

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Coverage determination

Process used by healthcare teams to determine suitable drug options, coverage criteria (steps), and estimated costs related to prescription medication claims.

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Medicare Establishment Year

Medicare was established in 1965 under Title XVIII of the Social Security Act.

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Medicare Eligibility (Initial)

Initially, Medicare covered citizens aged 65 and older.

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Medicare Expansion (1972)

Medicare expanded to cover individuals under 65 with end-stage renal disease (ESRD) and disabled individuals receiving Social Security Disability Insurance (SSDI).

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Medicare Expansion (2001)

Medicare expanded to cover individuals with amyotrophic lateral sclerosis (ALS).

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Medicare Funding

Medicare is managed by federal funding overseen by the Centers for Medicare & Medicaid Services (CMS).

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Medicare Part A Financing

Part A is primarily funded by a 2.9% payroll tax on both employers and employees (1.45% each).

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Medicare Part A Coverage

Part A covers inpatient hospital care (acute & post-acute), hospice care (life expectancy < 6 months), and home healthcare services, and all drugs in inpatient settings.

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Medicare Part A Enrollment

Part A enrollment is automatic for beneficiaries upon turning 65 and it has a $1,632 deductible (2024).

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Medicare Part D Drug Formulary

A list of prescription drugs that Medicare Part D plans cover. It's similar to a commercial insurance drug list.

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CMS Approval

The Centers for Medicare & Medicaid Services (CMS) approval is needed for medications to be included on the Part D formulary.

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Drug Formulary Tiers

Medicare Part D formularies usually have different coverage levels (tiers) for medications, with varying cost-sharing, meaning the more expensive the drug, the higher the tier.

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Pharmacy & Therapeutics (P&T) Committee

A committee of doctors & pharmacists that reviews new drugs & recommends their inclusion in the formulary.

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Formulary Revision

Changes to the list of covered drugs in a Medicare Part D plan.

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Catastrophic Coverage Phase

A Medicare Part D coverage phase triggered when a beneficiary reaches a high spending limit in the gap coverage phase.

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Open Enrollment Period

A specific timeframe where Medicare beneficiaries can make changes to their Part D plans.

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Cost Sharing

The amount a beneficiary pays for covered services like medicines.

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Study Notes

Pharmacoeconomics

  • The description and analysis of drug therapy costs to healthcare systems and society.
  • Also identifies, measures, and compares costs and consequences of pharmaceutical products/services.

Objectives

  • Define pharmacoeconomics.
  • Discuss the importance and clinical relevance of pharmacoeconomics to the practice of pharmacy and optimal provision of quality healthcare.
  • Identify common examples for the three (3) types of outcomes evaluated in pharmacoeconomic studies.
    • Clinical outcomes: Results of treatment with a drug (e.g., prevention, cure, adverse effects, toxicity).
    • Economical outcomes: Costs associated with a therapy (e.g., labor, equipment, monitoring).
    • Humanistic outcomes: Involves patients' point of view (e.g., patients' feelings and perceptions).
  • Identify and discuss the general characteristics of the four (4) most common pharmacoeconomic study types.
    • Cost minimization analysis (CMA)
    • Cost benefit analysis (CBA)
    • Cost effectiveness analysis (CEA)
    • Cost utility analysis (CUA)

Types of Pharmacoeconomic Studies

  • Cost minimization analysis (CMA):

    • Costs are measured in dollars.
    • Outcomes are assumed to be equivalent.
    • Examples include comparing therapeutically equivalent medications (e.g., glipizide and glyburide) or inpatient versus outpatient use of a medication.
    • Advantages: Simple study.
    • Disadvantages: Outcomes must be assumed equivalent.

  • Cost benefit analysis (CBA):

    • Measures both costs and outcomes in dollars.
    • Advantages: Allows assessment of whether benefits exceed costs. Provides comparison of multiple products/services with varied outcomes.
    • Disadvantages: Difficult to assign a monetary value to all health outcomes.
    • Example: Costs (inputs) of implementing a PK consulting or diabetes clinic vs. cost savings (outcomes) associated with the service.

  • Cost effectiveness analysis (CEA):

    • Measures costs in dollars ($) & outcomes in natural units (e.g., symptom-free days, mmHg, lives saved).
    • Advantages: Outcomes easier to quantify since health units are commonly used.
    • Disadvantages: Alternatives for comparison must have outcomes in the same units.
    • Example: BCBS-MS assesses the addition of a new blood glucose-lowering medication to its preferred formulary, but the daily dose of the new medication is more expensive.

  • Cost utility analysis (CUA):

    • Measures costs in dollars ($) and outcomes in health utilities, such as quality-adjusted life years (QALYs).
    • Advantages: Different health outcomes can be compared as a common unit (QALYs) without assigning monetary values. Used when morbidity and mortality are key factors.
    • Disadvantages: Difficult to determine an accurate QALY value.
    • Example: Assessing costs and utilities of two common chemotherapy regimens for non-small cell lung cancer.

Importance of Pharmacoeconomics

  • Increasing healthcare costs (e.g., $3.8 trillion in 2019, with $11,582 per person average)
  • 17.7% of gross domestic product (GDP) in the USA
  • $369.7 billion spent on prescription medications.

Benefits of Pharmacoeconomics

  • Doing more with fewer resources (e.g., $$$, labor).
  • Provides data to make important decisions related to healthcare.
    • Appropriate drug selection for hospital or insurance formulary.
    • Management strategies for certain disease states (e.g., guideline development).
    • Appropriate drug selection to treat patients' medical conditions.
    • Implementation of new services within a pharmacy, hospital, or clinic (e.g., MTM (medication therapy management), PK consulting, DSME (diabetes self-management education)).

Case Studies

  • Multiple case studies assessing cost-effectiveness for treating obesity or other diseases using pharmacoeconomic methods are presented.
  • The studies presented varied in their methods, outcomes, and populations examined.
  • Key statistics and findings extracted from the presented case studies are available.

Healthcare Provider & Payer Considerations

  • Healthcare providers aim to deliver optimal patient care and ensure patients achieve the best possible treatment results, considering various factors (e.g., demographics, clinical, social and economic).
  • Insurance payers strive to contain rising costs by properly assessing treatment costs alongside safety, efficacy, and effectiveness of treatment options.
  • Pharmacoeconomics assists both providers and payers in estimating benefits and the value of patient outcomes in relation to cost for medications and healthcare products/services.

Why Pharmacoeconomics?

  • Individual patients: Healthcare providers can use appropriate demographic, clinical, social, and economic factors when choosing the best medication and care plan.
  • Community level: Administrators assess costs and value when implementing a new service at a hospital or pharmacy.
    • Includes factors like profitability, improved patient outcomes, and improved quality of care.
  • Population level: Interprofessional teams work to determine the most efficient and effective therapies for various patient populations. Includes development of specific drug formularies and considerations for patient copays and costs.

Medicare Part D Prescription Drug Tiers:

  • Tier 1: Covers generic prescription drugs, with the lowest copay.
  • Tier 2: Covers preferred brand-name prescription drugs, with a medium level copay.
  • Tier 3: Covers non-preferred brand-name prescription drugs, with a higher level copay.
  • Specialty Tier: High-cost specialty drugs with a high copay.

Types of Pharmacoeconomic Studies

  • Summary table
    • Type of study, Cost Measurement Unit & Outcome Measurement Unit.

Cost-Minimization Analysis (CMA)

  • Example Case Study:
    • Comparing two generic drugs (e.g. metformin in different brands)
    • Comparing different antibiotics for pneumonia
    • Comparing once-daily versus every 8 hours dosing for an aminoglycoside
    • Description and discussion of cost minimization, including advantages and disadvantages of the method.

Midterm & Final Exam Review Materials

  • A comprehensive review of all topics covered in PHA 746 lectures.
  • Information regarding the format, topics, and resources for the mid-term and final examinations.

Advanced Modeling

  • Discussion of both decision analysis and Markov modeling, including advantages and disadvantages for each model.
  • Study steps necessary for both decision analysis and Markov modeling methods.

HRQoL Measures

  • Describes different types and methods of measuring health outcomes, including utility measures, quality-of-life measures (HRQoL), preference-based classification systems, and patient-reported outcomes (PROs) and the advantages and disadvantages.

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Description

Test your knowledge on the Medicare system, its coverage, and financing. This quiz also explores pharmacoeconomic concepts like cost utility and cost effectiveness analyses. See how well you understand these critical components of healthcare economics.

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