Healthcare system Final

Which entity typically manages prescription claims processing and formulary design on behalf of health plans?

A. Wholesalers

B. Pharmacy Benefit Managers (PBMs)

C. Hospital administrators

D. Federal government agencies

B

When a PBM establishes a preferred network of pharmacies, what primary factor is it trying to influence?

A. Patient satisfaction surveys

B. Pharmacy licensing standards

C. Drug importation policies

D. Overall prescription drug costs for plan sponsors

D

Which of the following best describes a Pharmacy & Therapeutics (P&T) Committee in the context of formulary management?

A. A government-appointed body that mandates prescription drug advertisements

B. A committee of pharmacists and physicians reviewing drug efficacy, safety, and cost

C. An insurance claims office that handles medication prior authorizations

D. A patient advocacy group dictating the lowest out-of-pocket costs for all medications

B

Which statement correctly distinguishes Cost-Benefit Analysis (CBA) from other economic evaluations?

A. CBA is the only approach that measures outcomes in “natural” health units like mm Hg or life-years.

B. CBA solely examines treatments that are already covered under Medicare Part D.

C. CBA converts both costs and outcomes into monetary terms, allowing direct comparison of net gains.

D. CBA disregards cost factors entirely and focuses only on patient-reported outcomes.

C

Which pharmacoeconomic method is most appropriate when two treatments are proven to have equivalent clinical outcomes, but differ in expense?

A. Cost-Minimization Analysis (CMA)

B. Cost-Utility Analysis (CUA)

C. Cost-Benefit Analysis (CBA)

D. Cost-Effectiveness Analysis (CEA)

A

In a Cost-Effectiveness Analysis, which of the following is a common outcome measure?

A. Dollars saved on supply chain management

B. Cost-to-charge ratio

C. Natural clinical endpoints (e.g., life-years gained)

D. Number of marketing campaigns conducted

C

Which of the following is considered an indirect cost in pharmacoeconomic evaluations?

A. Wages lost due to missed workdays for medical appointments

B. Medication copayments incurred by the patient

C. Physician consultation fees

D. Diagnostic lab test costs

A

Under Medicaid, which of these groups tends to have the highest per-capita spending despite making up a smaller proportion of total enrollees?

A. Low-income children

B. Low-income adults without disabilities

C. Elderly and individuals with disabilities

D. Temporary visitors in the state

C

Which statement about Medicaid eligibility is most accurate?

A. All states must cover every adult up to 300% of the federal poverty level.

B. Eligibility is uniform across all 50 states and does not allow state-specific variations.

C. States receive federal guidelines but can expand optional benefits or coverage groups.

D. Only inpatient hospital services are required; all outpatient coverage is optional.

C

Under Medicare Part C (Medicare Advantage), beneficiaries typically:

A. Receive hospital (Part A) and medical (Part B) services via private managed care plans.

B. Only gain access to hospice care and no other benefits.

C. Cannot choose prescription coverage as part of the plan.

D. Have no out-of-pocket maximum for covered services.

A

Which of the following correctly summarizes one of the 2025 changes to Medicare Part D?

A. Complete elimination of any monthly premiums for all beneficiaries

B. A new $2,000 annual out-of-pocket cap for prescription drug costs

C. Reinstatement of the coverage gap (“donut hole”) for brand-name drugs

D. Removal of catastrophic coverage provisions

B

A patient’s long-term care needs are most intensive in which of the following settings?

A. Assisted living facility

B. Skilled nursing facility (SNF)

C. Home health agency

D. Adult day care center

B

Which is not a reason patients might fail to persist with their chronic medication regimen?

A. They have chosen to switch to a lower-cost generic with physician approval.

B. They have side effects that make continued use difficult.

C. They perceive they’re not benefiting and stop taking it prematurely.

D. They cannot afford the copayment for monthly refills.

A

Direct-to-consumer advertising (DTCA) can lead to which potential negative outcome?

A. Reduced demand for brand-name drugs

B. Decreased public awareness of under diagnosed conditions

C. Higher costs for brand-name medications due to marketing expenditures

D. Immediate government approval of all newly advertised drugs

C

According to Commonwealth Fund rankings, the U.S. healthcare system typically performs least effectively in which areas, relative to other high-income countries?

A. Preventive screenings and immunizations

B. Administrative efficiency and cost-related access barriers

C. Technological innovation and specialized surgeries

D. Pediatric vaccination rates and sports injury management

B

In the context of drug shortages, which of the following is a primary contributing factor?

A. Unlimited manufacturing capacity among numerous competing manufacturers

B. Abundance of raw materials sourced from multiple local suppliers

C. Quality-control or manufacturing issues leading to production delays

D. Oversight by the FDA that automatically compensates for supply gaps

C

Which of the following best explains how pharmacists can help mitigate drug shortages?

A. Stockpiling critical drugs to avoid collaboration with other healthcare providers

B. Implementing usage guidelines, finding therapeutic alternatives, and communicating with teams

C. Eliminating all brand-name medications from the hospital formulary

D. Restricting patient access to only one type of medication regardless of clinical need

B

Which is an advantage of implementing blockchain technology in pharmaceutical supply chains?

A. Centralized data, so only one main server can edit transactions

B. Guaranteed 100% network speed for every global transaction

C. Enhanced traceability and transparency via an immutable ledger

D. Automatic bypass of FDA oversight for drug approval

C

In the discovery and development phase of pharmaceuticals, which challenge might blockchain help address?

A. Inability to recruit patients for clinical trials

B. Rapid acceptance of new drugs by all insurers

C. Secure sharing and validation of preclinical research data across multiple labs

D. Automatic human testing without IRB (Institutional Review Board) approval

C

Evergreening by a pharmaceutical company typically involves:

A. Voluntarily terminating all patents before their expiration date

B. Simplifying the drug formulation to reduce manufacturing cost

C. Creating new drug formulations or uses to extend market exclusivity

D. Increasing the presence of generic competitors for better patient access

C

Which long-term care service typically involves assistance with basic Activities of Daily Living (ADLs) but provides less medical oversight than a nursing home?

A. Assisted living facility

B. Hospice care

C. Skilled nursing facility

D. Rehabilitation hospital

A

Which of the following is an example of an optional Medicaid benefit that many states choose to cover?

A. Home health services

B. Outpatient hospital services

C. Prescription drugs

D. Physician services

C

From a pharmacoeconomic perspective, one key advantage of using QALYs (Quality-Adjusted Life Years) in decision-making is:

A. They measure only mortality and ignore quality of life.

B. They allow comparison of interventions across different diseases.

C. They produce identical results to cost-minimization analysis.

D. They are measured exclusively by physician surveys.

B

In Cost-Benefit Analysis (CBA), which question is a policymaker most likely to ask?

A. “How many additional QALYs does this drug provide?”

B. “How many days are spent in the hospital by patients in each group?”

C. “Do the total monetary benefits of this intervention exceed its total costs?”

D. “Is there proof that these interventions have identical outcomes?”

C

Dual eligibles are individuals who qualify for:

A. Medicare and Veterans Health Administration benefits

B. Medicaid and TRICARE

C. Both Medicare and Medicaid

D. Private employer insurance and charitable hospital coverage

C

Which statement best describes the concept of "spread pricing" in PBM operations?

A. PBMs pay the exact same rate to pharmacies that they charge to health plans.

B. PBMs earn revenue by charging health plans more for a drug than what they reimburse pharmacies.

C. Pharmacies negotiate directly with drug manufacturers, bypassing the PBM entirely.

D. Spread pricing refers to paying a premium to pharmacies for stocking brand-only medications.

B

When PBMs use closed formularies, they typically aim to:

A. Provide free samples to encourage patient adherence.

B. Include all possible brand and generic drugs for patient choice.

C. Restrict which drugs are covered, steering utilization to preferred agents.

D. Automatically approve all high-cost specialty medications.

C

Which of the following is an example of coinsurance?

A. A fixed amount a patient pays every time they fill a prescription (e.g., $10).

B. A percentage (e.g., 20%) of the medication’s total cost that the patient must pay.

C. A penalty that patients pay if they buy prescriptions out of network.

D. A fee that the pharmacy charges the patient for storing medication.

B

Step Therapy programs within a PBM context require:

A. Patients to receive medication therapy strictly via mail-order.

B. Patients to try lower-cost or first-line agents before “stepping up” to costlier alternatives.

C. A one-time exception process that bypasses all utilization controls.

D. Immediate approval of brand-name drugs without trying generics first.

B

Which of the following best distinguishes Cost-Utility Analysis (CUA) from other pharmacoeconomic methods?

A. CUA measures outcomes purely in cost savings for the hospital.

B. CUA focuses on patient preferences and quality-of-life weights (e.g., QALYs).

C. CUA only applies to medical devices and excludes prescription drugs.

D. CUA is identical to cost-minimization analysis if treatments share the same efficacy.

B

In a Cost-Effectiveness Analysis (CEA) taking a societal perspective, which costs would typically be included?

A. Only direct medical costs covered by insurers

B. Direct costs to insurers plus indirect costs such as lost wages and caregiver time

C. Only the patient’s out-of-pocket costs for doctor visits

D. Only intangible costs related to pain and suffering

B

Which of the following is considered an intangible cost?

A. Copayments for medication refills

B. Reduced productivity while at work (“presenteeism”)

C. Caregiver wages for assisting the patient

D. Pain and anxiety experienced by the patient

D

Activities of Daily Living (ADLs) include which of the following?

A. Handling investments and paying bills

B. Dressing, bathing, eating, toileting, transferring

C. General housekeeping and yard maintenance

D. Organizing family events and scheduling doctor’s appointments

B

Which statement about Medicaid expansion under the Affordable Care Act (ACA) is correct?

A. All 50 states are federally mandated to expand coverage to all adults up to 400% of FPL.

B. States could choose whether to expand Medicaid eligibility to a larger low-income adult population.

C. Medicaid expansion replaced Medicare for all seniors.

D. Medicaid expansion only applied to pregnant women and children.

B

Under Medicare Part B, which of the following services is least likely to be covered?

A. Outpatient mental health counseling sessions

B. Durable medical equipment (e.g., wheelchairs)

C. Routine physician office visits and diagnostic tests

D. Most outpatient prescription drugs for self-administration at home

D

Employer Shared Responsibility under the ACA requires:

A. All employers, regardless of size, to offer health insurance with no deductible.

B. Large employers (≥50 FTEs) to provide affordable coverage or pay a penalty.

C. Small businesses (fewer than 10 employees) to cover at least 80% of employees’ premiums.

D. Employers to reimburse employees directly for buying private individual coverage.

B

Which metal tier in the ACA Marketplace typically carries the highest monthly premium but lowest out-of-pocket costs?

A. Bronze

B. Silver

C. Gold

D. Platinum

D

In Medicare Part D, the term “coverage gap” (also known as the donut hole) historically referred to:

A. A period when beneficiaries paid 100% of drug costs after a certain threshold until catastrophic coverage.

B. A 30-day waiting period to sign up for a prescription drug plan.

C. A mandatory delay in coverage for brand-name drugs only.

D. A complete exemption from cost-sharing for low-income beneficiaries.

A

Under Cost-Benefit Analysis, which question best reflects the core decision rule?

A. “Are the clinical outcomes equal, making the cheaper option preferable?”

B. “Does the intervention’s monetary benefit exceed its total monetary cost?”

C. “Is the QALY gain above a threshold of $50,000?”

D. “Is the cheapest medication also the most effective for every patient?”

B

Which element best differentiates Medigap (Medicare Supplement) policies from Medicare Advantage (Part C)?

A. Medigap replaces Original Medicare with a private HMO or PPO network.

B. Medigap policies are sold by pharmacies to reduce generic drug costs.

C. Medigap helps cover Original Medicare Part A/B out-of-pocket costs, whereas Part C is a private plan that bundles A/B (and often D).

D. Medigap is managed exclusively by the federal government with no private involvement.

C

Which quality measure is not typically included in the CMS 5-Star Rating System for nursing homes?

A. Overall staffing level

B. Use of chemical restraints

C. Incidence of pressure ulcers

D. Cost of monthly rent for private rooms

D

A Consultant Pharmacist in a long-term care facility is primarily responsible for:

A. Diagnosing common conditions like diabetes or hypertension.

B. Reviewing medication regimens for appropriateness and optimizing therapy.

C. Setting all facility meal plans and nutritional guidelines.

D. Replacing the primary care physician in prescribing all treatments.

B

In the pharmaceutical approval process, which phase examines a drug’s safety and dosage with a small number of healthy volunteers?

A. Phase 1

B. Phase 2

C. Phase 3

D. Phase 4 (Post-marketing)

A

Which of the following is not typically a factor leading to drug shortages?

A. A single supplier producing the active ingredient

B. Robust competition with multiple backup manufacturers

C. Manufacturing quality control failures forcing a plant shutdown

D. Natural disasters disrupting supply chain logistics

B

One potential downside of direct-to-consumer pharmaceutical advertising is:

A. It completely eliminates patient interest in brand-name drugs.

B. It has eradicated the coverage gap for seniors.

C. It may lead to over utilization or patient pressure to prescribe more expensive therapies.

D. It requires minimal regulatory oversight from the FDA.

C

According to the Commonwealth Fund assessments, one major reason the U.S. lags behind other wealthy nations is:

A. Universal coverage leads to poor outcomes in other countries.

B. Excessive out-of-pocket costs and fragmented care deter many Americans from early treatment.

C. The U.S. invests the least in prescription drug development.

D. There are no private insurance options available to Americans.

B

Value-based payment models (e.g., Accountable Care Organizations) typically strive to:

A. Reimburse providers solely based on the number of services (fee-for-service).

B. Pay providers more if patients experience higher rates of hospital readmissions.

C. Align provider payments with improved patient outcomes and cost savings.

D. Mandate no hospital admissions for any patients over 65.

C

Which factor contributes most to high drug prices in the U.S. pharmaceutical market?

A. Universal acceptance of price controls by all U.S. insurers

B. Lack of research and development costs among pharma companies

C. Patent protections and limited competition for novel drugs

D. Strict federal caps on brand-name drug prices

C

In Medicare Part D plans, a “formulary” refers to:

A. The complete set of all prescription drugs a plan must cover at no cost.

B. The official list of prescription drugs covered by the plan, often organized by tiers.

C. A drug reference manual used solely by pharmacists for compounding instructions.

D. A federal mandate requiring all brand-name drugs to be fully covered.

B

Medication Therapy Management Programs (MTMP) under Medicare Part D aim to:

A. Replace physician oversight by directly prescribing medications.

B. Provide comprehensive medication reviews and interventions to optimize drug therapy.

C. Restrict the list of formulary drugs to only high-cost specialty agents.

D. Increase cost-sharing for patients with chronic conditions.

B

Which of the following roles is commonly associated with a PBM’s clinical staff?

A. Setting federal regulations for prescription drug labeling

B. Negotiating patients’ monthly premiums with employers

C. Designing prior authorization criteria and step-therapy protocols

D. Issuing pharmacy technician licenses at the state level

C

In the PBM business model, rebates from manufacturers are generally:

A. Minimal incentives that have no impact on net drug costs

B. Negotiated discounts or reimbursements from brand drug makers to the PBM

C. Extra fees that plan sponsors must pay directly to pharmacies

D. Fully transparent in all cases to the general public and patients

B

Pharmacy networks managed by PBMs typically:

A. Permit any pharmacy to join without any contract

B. Include only pharmacies owned exclusively by the PBM

C. Have predetermined reimbursement rates and rules for member pharmacies

D. Operate like a loyalty card program with no written agreements

C

Which utilization management method ensures a patient meets specific diagnostic or clinical criteria before a medication is approved?

A. Quantity limits

B. Prior authorization

C. Step therapy

D. Therapeutic substitution

B

Formulary tiers typically encourage use of lower-cost medications by:

A. Restricting generics to specialty clinics only

B. Charging higher copays for preferred drugs than for non-preferred

C. Requiring no out-of-pocket payments for brand-name drugs

D. Charging lower copays for preferred generics than for higher-tier medications

D

A Cost-Minimization Analysis (CMA) is valid under the assumption that:

A. Clinical outcomes of the compared interventions differ significantly

B. The analysis includes intangible costs and QALY estimates

C. Both treatments offer equivalent clinical efficacy, focusing only on cost differences

D. All cost figures are expressed in intangible, non-financial metrics

C

Which answer best describes a scenario for Cost-Benefit Analysis (CBA)?

A. Evaluating whether a generic antidepressant yields the same clinical outcomes as a branded version

B. Calculating cost per extra month of survival for a new oncology treatment

C. Converting both the costs and benefits of an immunization program into dollars to see if benefits exceed costs

D. Measuring patients’ satisfaction scores (1–5) for a newly approved cholesterol medication

C

In a Cost-Effectiveness Analysis (CEA), an Incremental Cost-Effectiveness Ratio (ICER) usually indicates:

A. The additional cost required to produce one additional unit of effectiveness (e.g., one life-year gained)

B. The ratio of intangible costs to intangible benefits in monetary form

C. A measure of how cost is minimized under identical outcome assumptions

D. The difference in direct costs between brand and generic drugs with no clinical measure

A

For a Cost-Utility Analysis (CUA), the typical outcome measure is:

A. Total hospital stays

B. Number of prescriptions filled

C. Quality-adjusted life years (QALYs)

D. Number of therapy sessions completed

C

One key disadvantage of using a Cost-Utility Analysis is:

A. It cannot compare interventions for different diseases

B. Calculating quality-of-life measures (utilities) can be subjective and complex

C. It disregards patient preferences and only focuses on cost

D. Utility-based results cannot be used in health policy decisions

B

Skilled Nursing Facilities (SNFs) differ from Nursing Homes primarily in that SNFs:

A. Provide only custodial care with no nursing services

B. Supply intense daily therapy (e.g., physical/occupational), targeting short-term rehabilitation

C. Restrict patient admission to those under 18 years of age

D. Usually do not accept Medicare or Medicaid reimbursements

B

Home Health Care typically serves patients who:

A. Are capable of complete self-care with no professional support

B. Require advanced hospital-based treatment 24 hours a day

C. Benefit from periodic nursing or therapy visits but can remain in their residence

D. Reside permanently in a skilled nursing facility (SNF)

C

Which of the following statements about Long-Term Care (LTC) facilities is accurate?

A. They strictly house patients receiving acute inpatient surgeries

B. They are covered by Medicare Part D for all medical and pharmacy benefits

C. LTC includes various options such as assisted living, nursing homes, and hospice services

D. LTC strictly excludes any skilled therapy services or hospice care

C

Medicaid is primarily financed through:

A. Employer payroll taxes only

B. 100% funding from the federal government with no state contributions

C. Joint federal–state funding with state-based matching percentages

D. Premium payments from Medicare beneficiaries

C

The Mandatory eligibility groups for Medicaid do not typically include:

A. Children in low-income families

B. Low-income pregnant women

C. Individuals with significant investment income over the threshold

D. Individuals receiving Supplemental Security Income (SSI)

C

In Medicaid, the population segment often referred to as “dual eligibles” includes:

A. Children who qualify for both SNAP (food stamps) and TANF (cash assistance)

B. Adults who have coverage through their employer and a PBM discount program

C. Individuals eligible for both Medicaid and Medicare

D. Only those receiving veterans’ benefits plus private insurance

C

Medicare Part A primarily covers:

A. Physician office visits and outpatient procedures

B. Inpatient hospital stays, skilled nursing care, and hospice

C. Routine dental care and over-the-counter medications

D. Retail prescription drugs self-administered at home

B

A key difference between Medicare Part B and Part D is that Part B:

A. Provides the same coverage as Part D but for seniors over age 70

B. Covers outpatient physician services and some infusion drugs administered in a clinic

C. Covers retail prescriptions filled at pharmacies for home use

D. Excludes any coverage for preventive services

B

An Accountable Care Organization (ACO) is best described as:

A. A group of PBMs working to reduce all brand-name drug costs

B. A collection of hospitals, doctors, and other providers collaboratively managing care for Medicare beneficiaries

C. A government agency that directly oversees all private insurance claims

D. An extended pharmacy network handling prior authorizations for specialty meds

B

One primary aim of the Affordable Care Act (ACA) was to:

A. Abolish all forms of private health insurance

B. Enforce universal Medicaid coverage for every adult under 65

C. Expand access to health insurance via marketplaces and subsidize premiums for lower-income enrollees

D. Remove coverage mandates for preventive services

C

Direct-to-consumer advertising (DTCA) of pharmaceuticals is:

A. Prohibited by law in the United States for all prescription medications

B. Uncommon, since most manufacturers prefer not to market to the public

C. Regulated by the FDA for accuracy and balance of benefits and risks

D. Only permitted on social media platforms for over-the-counter drugs

C

Under pharmacoeconomic frameworks, “indirect costs” often refer to:

A. Co-insurance fees paid by patients at the pharmacy

B. Lost wages or productivity due to illness or disability

C. Annual deductible amounts for hospital admission

D. Direct medical expenses like surgery and medications

B

Drug shortages can be aggravated by:

A. Multiple manufacturers producing an identical generic drug

B. Reliable quality control checks at multiple facilities

C. Sole-source manufacturing where only one plant produces a critical API

D. Having robust backup distribution channels in different regions

C

The term “evergreening” in pharma marketing often indicates that:

A. All generics are sold under one universal brand

B. Patents are extended or new patents are filed for slight drug modifications

C. The brand drug is immediately withdrawn from the market after its patent expires

D. The FDA automatically substitutes brand prescriptions with biosimilars

B

The World Health Organization (WHO) has noted that the U.S.:

A. Ranks number one in healthy life expectancy among all high-income nations

B. Spends significantly less on healthcare than any other OECD country

C. Has a lower life expectancy compared to other high-income nations despite high spending

D. Prohibits cost-effectiveness data in coverage decisions

C