Managed Care 101
This professional pharmacy organization includes ~ 8,000 members who manage medication therapies for Americans with insurance.
What is AMCP? Academy of Managed Care Pharmacy. Similar to ASHP, they offer conferences/network events, Pharmacy CE, and internships and residencies.
There are two primary reimbursement systems for healthcare delivery in the US; Value-based reimbursement and X.
What is the Fee for Service system? Healthcare providers are paid a fee for each particular service which rewards volume and quantity, regardless of outcome.
Value-Based Healthcare can lower reimbursement for adverse events and poor outcomes.
What is True? Specific metrics/requirements must be satisfied to obtain a 100% reimbursement value. If the metric is not met, providers are not fully reimbursed for the care provided.
Definition: discrepancy between recommended best healthcare practices and the care that is actually provided.
What is a clinical gap in care? Many drug-related metrics for VBR programs are related to clinical gaps in care.
Managed Care pharmacy practice is primarily concerned with a. individual patient care or b. population-based care.
B. What is Population-Based Care? Practitioners in this space use strategies to impact the greater good, often 1,000s or 1,000,000 of patients will be affected by a decision.
This national government organization is leading the charge for the transition to value-based healthcare.
What is the Centers for Medicare and Medicaid Services (CMS)? Federal agency within the Department of Health and Human Services.
There is no financial incentive to implement Electronic Health Record (EHR) systems which is why adoption is low.
What is false? One of the hallmarks of the Patient Protection and Affordable Care Act is provision of a financial incentive to implement EHR systems. Nearly 86% of healthcare providers have EHR connectivity.
This term is the industry standard for measuring patient medication adherence based upon RX claims.
What is Proportion of Day Covered or PDC? Threshold value for adherence is X%
We discussed 4 areas of managed care practice; clinical, business, patient care, and client-management. Formulary management would be categorized as....
What is clinical managed care practice? Practitioners in this space should have good research and literature skills.
In regards to healthcare reform, this concept of better health, better care, and lower cost is often referenced.
What is the Triple Aim? This is considered the framework to help optimize healthcare performance. Often focuses on high-risk populations.
A Patient-Centered Medical Home (PCMH) is a type of long-term care residential facility for persons with chronic disease states.
What is false? PCMH is care model in which a primary care practice or group of practices accepts responsibility for managing the health of defined population.
In community pharmacy, coordination of refills by the pharmacy to be picked up on a single day each month can improve adherence. What is this process called?
What is medication synchronization? This process can help patients receive all of their chronic meds and allows a scheduled time for pharmacist consultation and other care services.
A pharmacist/technician may encounter a prior authorization, step therapy, or quantity limit edit during claims adjudication with the PBM. Collectively, these 3 types of edits are called..
What are Trend Management edits? This is one of the services available to PBM customers.
This is generally considered the rate-limiting step when implementing a value-based healthcare program. a. Staff resources b. information technology c. medical community cooperation
What is b. information technology? Efficient and effective IT systems are needed for care coordination, payments, and to receive/aggregate data.
Value-Based Healthcare arrangements can generate shared savings for their participants.
What is true? Gainsharing is an financial model in which providers receive a portion of the savings attributable to changes in clinical practice. Often times seen with Accountable Care Organizations.
The SUPD measure is a widely adopted value-based pharmacy metric. What does it stand for?
What is Statin Use for Persons with Diabetes? Based on American Diabetes Association recommendations, the goal is to reduce risk of cardiovascular events and death.
What % of RXs do PBMs process in the US?
a. 80% b. 85% c. 90%
What is c. 90%. Every 9 out of 10 RXs in the US interacts with a PBM adjudication platform to deliver information about claim such as eligibility, cost, and alternatives.
Data is the new healthcare currency. These two data insights are critical to a successful value-based program: Total cost-of-care information AND.....
What is peer-benchmarking? Providers are more willing to change their behavior if they understand what their peers are doing.
High-cost specialties such as GI, cardiology, and oncology are at the center of the value-based reimbursement movement.
What is false? VBR is anchored by primary care providers. Under requirements set forth by CMS and likely adopted for commercial reimbursement, the PCP is ultimately responsible for total patient care.
This is the scale that is used by the Centers for Medicare and Medicaid Services (CMS) to rate the quality of Medicare Plans. Several pharmacy metrics are included as indicators of quality.
What is the CMS Star Ratings? The scale ranges from 1-5 and is updated annually. Adherence and SUPD drug measures are included.