Third-Party Payers: Private Health Insurance

Nationally, commercial reimbursement for healthcare services are _____ that of Medicare fee-for-service payment rates

196%

What is the primary reason health insurance provides "peace of mind"?

The payer accepts the financial risk of healthcare expenses

Which type of commercial insurance is typically for businesses with <50 employees?

Small group

Which type of commercial insurance is typically short-term or supplemental?

Underwritten

Which type of commercial insurance includes ACA and non-ACA?

Individual

Which type of commercial insurance is typically for businesses with 500+ employees?

Large Group/National

Who are the key players in the commercial health insurance ecosystem?

1. Insurance carriers

2. Pharmacy benefit managers (PBMs)

3. Employers and employer groups

4. Drug manufacturers

Which key player in the commerical-health insurance ecosystem provides health insurance plans to employers and individuals?

Insurance carriers

Which key player in the commerical-health insurance ecosystem manages pharmacy benefit on behalf of insurers and employers?

PBMs

Which key player in the commerical-health insurance ecosystem pays for health benefits (directly/indirectly) and many approve benefit exception, decide co-pay structures, opt-into certain programs, elect to cover certain drugs/categories, etc?

Employers and employer groups

Which key player in the commerical-health insurance ecosystem influence formulary and utilization barriers via rebates and offers co-pay assitance programs?

Drug manufactuerers

Which is an employer-based insurance?

Employer purchases a group-health plan or self-funds coverage through a health insurance company

__________ insurance is the largest source of health coverage in the U.S. below the age of 65

Employer-based

What is the health insurance marketplace?

Federal or state-run platforms where individuals/families can (1) compare health plans, (2) evaluate provider networks and drug formularies, (3) check eligibility for premium tax credits or cost-sharing reductions, (4) enroll in ACA-complaint plans

The health insurance marketplace was established under the...

Affordable care act (ACA)

The health insurance marketplace is a safety net for individuals who...

lack employer-sponsered coverage

The health insurance marketplace is categorized by.....

Metal levels (bronze, silver, gold, platinum) based on cost-sharing

What do health insurance companies do?

In essence, they act as the financial middleperson. They contract with plan sponsors—like employers—who pay premiums. In turn, the insurance company helps pay for covered health services. Patients receive care from providers, pay smaller portions (like copays), and the insurance company reimburses providers based on the contract. Essentially, they help manage the financial risk, making healthcare costs more predictable for everyone involved.

Which of the following are included in the "triple aim"?

D) All of the above

3 multiple choice options

What is the managed care pharmacist's role?

Clinical programs, preventing fraud/waste/abuse, education + collaboration, utilization management, formulary management, network and rebate negotiations

What three (3) macro themes are proliferating in healthcare and transforming the market?

1. The shift to value-based care is accelerating

2. Consumer engagement comes first

4. Technology is driving healthcare information

Which of the following is true regarding the shift to value-based care?

Through several different models are being employed, vertical integration and delivery disruption are changing how consumers receive care and who pays for it

Which of the following are examples of vertically integrated relationships in the drug channel?

(Select ALL that apply)

1. Insurer

2. PBM

3. GPO

4. Manufacturer

5. Wholesale distribution

6. Specialty/Mail

7. Retail/LTC pharmacy

8. Provider

Healthcare consumer expectations continue to increases as out-of-industry players (e.g. uber, netflix, apple, amazon) deliver constantly improving experiences.

True

1 multiple choice option

Which of the following reflects how the shift to value-based care is expanding the pharmacist's role?

All of the above

3 multiple choice options

How is consumer engagement influencing the role of pharmacists?

All of the above

3 multiple choice options

How is technology driving innovation in pharmacy practice?

All of the above

3 multiple choice options