Podcast
Questions and Answers
Which country has the highest average life expectancy according to the data provided?
Which country has the highest average life expectancy according to the data provided?
What is the healthcare spending per person in the United States as of 2022?
What is the healthcare spending per person in the United States as of 2022?
Which criteria is NOT considered when evaluating the quality of healthcare?
Which criteria is NOT considered when evaluating the quality of healthcare?
Which country ranks third in healthcare quality based on the factors provided?
Which country ranks third in healthcare quality based on the factors provided?
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Which of the following countries ranks highest in healthcare spending per capita?
Which of the following countries ranks highest in healthcare spending per capita?
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How does the average life expectancy in the United States compare to that of Hong Kong?
How does the average life expectancy in the United States compare to that of Hong Kong?
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In terms of healthcare quality, where does the United States rank compared to other countries?
In terms of healthcare quality, where does the United States rank compared to other countries?
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What is one of the factors considered when determining the quality of healthcare?
What is one of the factors considered when determining the quality of healthcare?
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What percentage of GDP did U.S. healthcare spending reach in 2022?
What percentage of GDP did U.S. healthcare spending reach in 2022?
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Which of the following factors contributes to the complexity of obtaining health insurance in the U.S.?
Which of the following factors contributes to the complexity of obtaining health insurance in the U.S.?
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Which demographic factor can influence eligibility for health insurance in the U.S.?
Which demographic factor can influence eligibility for health insurance in the U.S.?
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What is a common characteristic of the U.S. healthcare system as stated?
What is a common characteristic of the U.S. healthcare system as stated?
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Why is the current U.S. healthcare system described as inflationary and wasteful?
Why is the current U.S. healthcare system described as inflationary and wasteful?
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Which is not a typical barrier to obtaining health insurance in the U.S.?
Which is not a typical barrier to obtaining health insurance in the U.S.?
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What is one of the implications of having 26 million people without health insurance in 2022?
What is one of the implications of having 26 million people without health insurance in 2022?
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How does U.S. healthcare spending per person compare to other wealthy countries?
How does U.S. healthcare spending per person compare to other wealthy countries?
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What is a potential issue faced by international visitors regarding health insurance in the US?
What is a potential issue faced by international visitors regarding health insurance in the US?
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What does the term 'underinsured' imply in the context of multiple insurance plans?
What does the term 'underinsured' imply in the context of multiple insurance plans?
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What is a significant contributor to medical errors being a leading cause of death in the US?
What is a significant contributor to medical errors being a leading cause of death in the US?
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Which group is most likely to experience excess healthcare utilization?
Which group is most likely to experience excess healthcare utilization?
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What percentage of diagnostic errors is estimated for various conditions?
What percentage of diagnostic errors is estimated for various conditions?
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What might contribute to the maldistribution of healthcare access?
What might contribute to the maldistribution of healthcare access?
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What is a common issue faced by patients who are uninsured or underinsured?
What is a common issue faced by patients who are uninsured or underinsured?
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What trend was observed in outpatient medication errors between 1983 and 1993?
What trend was observed in outpatient medication errors between 1983 and 1993?
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Which payment method requires providers to deliver all needed care for their population for a specified period?
Which payment method requires providers to deliver all needed care for their population for a specified period?
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What is a characteristic feature of HMOs in terms of provider networks?
What is a characteristic feature of HMOs in terms of provider networks?
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In which type of HMO do providers have no risk but may be influenced by utilization reviews?
In which type of HMO do providers have no risk but may be influenced by utilization reviews?
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What mechanism manages risks and claims that exceed projections in an HMO?
What mechanism manages risks and claims that exceed projections in an HMO?
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Which managed care organization type allows individuals to see any provider but has a financial incentive to choose within a network?
Which managed care organization type allows individuals to see any provider but has a financial incentive to choose within a network?
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What defines the network-model HMO's approach to contracts with providers?
What defines the network-model HMO's approach to contracts with providers?
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What is the role of a gatekeeper in an HMO?
What is the role of a gatekeeper in an HMO?
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What distinguishes Exclusive Provider Organizations (EPOs) from other types of managed care organizations?
What distinguishes Exclusive Provider Organizations (EPOs) from other types of managed care organizations?
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What is the primary benefit of a PBM utilizing limited networks?
What is the primary benefit of a PBM utilizing limited networks?
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How are rebates typically structured in relation to PBMs?
How are rebates typically structured in relation to PBMs?
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What is the role of the NCPDP in claims adjudication?
What is the role of the NCPDP in claims adjudication?
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Which type of formulary allows all drugs to be covered?
Which type of formulary allows all drugs to be covered?
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Which tier in an incentivized formulary typically has the lowest copayment?
Which tier in an incentivized formulary typically has the lowest copayment?
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What is required from a physician for a medication under a non-preferred tier?
What is required from a physician for a medication under a non-preferred tier?
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Step-therapy requires patients to first try which type of medications?
Step-therapy requires patients to first try which type of medications?
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What approach allows pharmacists to dispense therapeutically-equivalent drugs without a new prescription?
What approach allows pharmacists to dispense therapeutically-equivalent drugs without a new prescription?
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Study Notes
US Healthcare System
- The US healthcare system is characterized by high spending but not necessarily higher life expectancy or quality of healthcare compared to other wealthy countries.
- The US spends roughly twice as much per person on healthcare compared to other wealthy countries.
- The US healthcare system is fragmented, with many different ways to get insurance, which can be confusing and time-consuming.
- The US has the highest healthcare standards, with professional and facility licensures and certifications, as well as advanced technology available.
- The US healthcare system is inflationary, wasteful, and unfair.
- There are significant socioeconomic and racial disparities in healthcare outcomes in the US.
- The US healthcare system is characterized by excess care (waste) for some and too little care for others, with factors like insurance coverage playing a large role.
- The US healthcare system is also subject to maldistribution, where high socioeconomic patients have access to better healthcare, while lower socioeconomic patients face reduced access and higher costs.
Excess Care
- Out-of-network coverage is a major contributing factor to excess care in the US.
- Managed Care Organizations (MCOs) are designed to control healthcare costs by managing provider networks and patient access.
- Health Maintenance Organizations (HMOs) are a type of MCO that generally only cover care received within their network, with providers bearing some financial risk.
- Preferred Provider Organizations (PPOs) are another type of MCO that allows individuals to see any provider but provides incentives for using in-network providers.
PBM Services
- Pharmacy Benefit Managers (PBMs) are companies that manage prescription drug benefits for health plans.
- PBMs negotiate discounts and rebates with pharmaceutical manufacturers, which can be based on factors like formulary status, prescribing volume, and market share.
- PBMs also manage claims adjudication, formulary status, prior authorization, and therapeutic alternatives.
- PBMs often utilize tiered copayment systems that encourage the use of preferred drugs over more expensive options. These tiers can include generic drugs, preferred brands, non-preferred brands, lifestyle drugs, and non-formulary drugs.
Formularies
- Formularies are lists of approved drugs that are covered by a health plan.
- Formularies can be open, closed, or incented.
- Open formularies cover all drugs.
- Closed formularies only cover drugs on the list.
- Incented formularies offer financial incentives to use preferred drugs, often through tiered copayment systems.
- Prior authorization programs require physicians to request approval from the PBM before certain drugs are covered.
- Step-therapy programs require less expensive first-line drugs to be proven ineffective before more expensive second-line drugs are covered.
- Therapeutic alternative programs allow pharmacists to dispense therapeutically equivalent drugs instead of the prescribed drug.
- Therapeutic interchange (or conversion) programs involve contacting the prescribing physician and patient for approval before a therapeutic alternative is dispensed.
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Description
Explore the complexities of the US healthcare system, which, despite high spending, shows disparities in outcomes and quality compared to other wealthy nations. This quiz covers various aspects, including fragmentation, wastefulness, and socioeconomic inequalities affecting healthcare access and quality.
