Econ Exam 3

body of clinical, financial and organizational activities designed to ensure provision of appropriate health care services in a cost efficient manor.

• fee for service
• health maintenance organizations
• preferred payer organizations
• point of service

amount of risk borne by the providers

relationship between the managed care organization and the physicians

whether physicians provide care to patient sfrom one managed care organization or to patient from multiple managed care organizations

wheter care received from a provider who is not in managed care organizatin's network is a covered benefit

• 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

• 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

• staff model
• group model
• network model
• independent practive association model

directly empoys its physicians

• 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

non-exclusive contracts with large medical groups

non-exclusive contracts with solo or small physician groups

• 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

• providers bear no risk
• less restrictive

• type of PPO
• no coverage outside provider network

• 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

no

yes

yes

yes

no

no

varies

staff

large group

several large groups with no exclusivity

solo or small group

solo or group

solo or group

varies

yes

yes

no

no

no

no

varies

no

no

no

no

yes

no

yes

• assume financial risk
• advocate for improving patient care
• help control healthcare costs
• encourage continuity of care
• better oversight of patient care (entire patient picture)

• small portion of overal healthcare costs
• pharmacies do not bear risk

• cost to fill a prescription
• medication cost + dispensing fee

usually calculated over a year

costs of processing a rx claim

• manage pharmaceutical benefits for managed care organizations, medical providers or employers
• pharmacy networks
• lower costs
• online ajudication of claims

• contract rate
• maximum allowable cost
• usual and customary price

• percentage of average wholesale price with a dispensing fee
• looks at brand prices

looks at generic prices with a dispensing fee

cash price

discount given to PBM by manufacturer based on formulary decisions

the use of safe, effective and most affordable medications

• open
• closed
• incented

everything is covered

not on formulary is not covered

step or tiered formularies

• PAs
• step therapies
• quantity limits
• refill limits
• generic substitution
• therapeutic interchange

large prescription volumes

discounted copays

pharmacist inputs code to override

pharmacy must contact PBM for code to override

• review use of drugs
• ensure appropriate medication use

• prospective
• retrospecitve

conducted at the time the rx is dispensed

primary goal is to educate PBM to see which physicains aren't prescribing medications appropriately

quality/cost

identical

• natural units
• different amounts

QALYs

$

• Drug compay prepares
• report on drug product
• used for P&T committees

• Product information
• supporting clinical and economic information
• economic value
• other
• references

description and place in therapy

• published and unpublished
• efficafcy and effectiveness trials

summary of clinical and economic impact as it pertains to the MCO

off label info

• may contain bias
• model transparency

• prepared by health system or MCO
• detailed report on drug product
• similar sections as a dossier
• data tailored to organization

• control-experiment
• used when outcomes are statistically significantly different

• control-experiment / control
• can be misleading
• commonly presented in clinical trials

1/ARR

1/2% = 50 patients treated to prevent 1 death

• 1/ARI
• only used when adverse event is significantly higher in one group vs. the other

• predict budgets for upcomming years
• analyze impact of a new treatment

• population size and characteristics
• costs of new treatment
• cost of treatments the new treatment is replacing (if any)

(total cost/number of members)/number of months