Health Systems Final Exam
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234 Terms
PHARMACY INDUSTRY
A three-tier system entails wholesalers, retail pharmacies, and ____________________.
manufacturers
PHARMACY INDUSTRY
What type of groups are formed to negotiate price with suppliers?
Purchasing
PHARMACY INDUSTRY
Who oversees drug safety, efficacy, marketing, and labeling at the federal level?
FDA
PHARMACY INDUSTRY
Argument that educate, inform, and empower patients, encourage compliance and remove stigma are known as __________________ arguments.
pro
PHARMACY INDUSTRY
These arguments misinform patients, lead to in appropriate prescribing and are not rigorously regulated.
Con
PHARMACY INDUSTRY
______________________ argument causes marketing battles.
Against
PHARMACY INDUSTRY
What act was put in place to provide tax incentive and enhanced patient protection for uncommon diseases?
Orphan Drug Act
PHARMACY INDUSTRY
_________________ drugs enter the market bringing no new health benefit.
Me-too drugs
PHARMACY INDUSTRY
What requires transparency in financial relationships between medical device manufacturers, physicians, pharmaceutical etc, specifically in payments to doctors greater than $10?
Sunshine Act
PHARMACY INDUSTRY
Another term to refer to the biopharmaceutical drug industry.
Pharma
PHARMACY INDUSTRY
How are vast amounts of money invested?
Lobbying
PHARMACY INDUSTRY
Who is often overlooked as "middle-men"?
Wholesalers
PHARMACY INDUSTRY
In a hospital, P&T committees help to determine a hospital's ________________________.
formulary
PHARMACY INDUSTRY
Who creates and manages outpatients' formularies on behalf of insurance companies?
PBM
HEALTH INSURANCE PAYERS
ACA requirement for everyone to have health insurance led to the creation of a health plan _____________________.
marketplace
HEALTH INSURANCE PAYERS
A ________________________ is a monthly subscriber fee to maintain enrollment in health insurance plan.
premium
HEALTH INSURANCE PAYERS
A fixed dollar amount the beneficiary must pay for certain services.
Copayment
HEALTH INSURANCE PAYERS
A __________________________ is a fixed dollar amount the beneficiary must pay entirely out of pocket before insurance begins to pay.
Deductible
HEALTH INSURANCE PAYERS
What is a fixed payment for healthcare regardless of the amount or types of services eventually rendered in the care of an individual and is a method used by organizations to control healthcare costs.
Capitation
HEALTH INSURANCE PAYERS
A percentage of a bill the beneficiary must pay.
Coinsurance
HEALTH INSURANCE PAYERS
Low premium/high deductible plans in which employers provide funds for employees to use for out of pocket medical expenses.
Flexible spending accounts
HEALTH INSURANCE PAYERS
This term is the trend toward more risk behavior when a person knows they are protected from future consequences.
Moral hazard
HEALTH INSURANCE PAYERS
The simplest and most popular type of plan prior to the managed care revolution.
Indemnity
HEALTH INSURANCE PAYERS
This type of insurance is the largest proportion of private insurance coverage in the United States.
Employer sponsored
HEALTH INSURANCE PAYERS
Part A and Part B of Medicare are considered _______________ Medicare.
Traditional
HEALTH INFORMATION TECHNOLOGY
Has reduced prescribing errors.
E-prescribing
HEALTH INFORMATION TECHNOLOGY
The ability of systems to communicate with each other.
Interoperability
HEALTH INFORMATION TECHNOLOGY
EHRs span across a _________________ of facilities.
network
HEALTH INFORMATION TECHNOLOGY
CliniSync and OARRS are examples of Electronic Health Information ______________ Networks for pharmacies.
Exchange
HEALTH INFORMATION TECHNOLOGY
EHR stands for Electronic _______________ Records.
Health
HEALTH INFORMATION TECHNOLOGY
What act incentivized adoption of EHRs? American Recovery and __________________ Act of 2009.
Reinvestment
HEALTH INFORMATION TECHNOLOGY
The applications of electronic systems to organize and use health data is Health _________________ Technology.
Information
HEALTH INFORMATION TECHNOLOGY
An example of pharmacy technologies are _________________ pill counters.
automatic
HEALTH INFORMATION TECHNOLOGY
EMRs are _____________ specific.
provider
HEALTH INFORMATION TECHNOLOGY
One of the goals of health information technology include increasing ______________.
efficiency
HEALTH INFORMATION TECHNOLOGY
Used to automate Prior Authorizations.
CoverMyMeds
HEALTH INFORMATION TECHNOLOGY
TeleHealth led to large advancements in ________________ medicine.
rural
HEALTH INFORMATION TECHNOLOGY
How many stages of implementation were there for EHRs?
Three (3)
HEALTH INFORMATION TECHNOLOGY
An EHR is _________________ term records from multiple providers and locations.
long
PBM
The process medications go through to get from manufacturer to pharmacies.
Supply chain
PBM
Part responsible for ensuring that pharmacies receive the highest reimbursement possible for purchasing drugs.
PSAO
PBM
Lowest price available from the manufacturer during the rebate period to any entity in the U.S. in any pricing structure for brand name medications.
Best price
PBM
Most commonly used benchmark for determining cost for pharmacies to purchase drugs.
WAC
PBM
Party responsible for leveraging purchase power of a group of businesses to acquire drugs at a lower cost due to collective buying power.
GPO
PBM
Payer of PBM determined price that ensures that the cost of generic medications is the same across manufacturers.
MAC
PBM
Average wholesale price calculated by what is paid by retail pharmacies for prescription and OTC drugs.
NADAC
PBM
Average price paid to the manufacturer for the drug in the U.S. by wholesalers for drugs distributed to the retail pharmacy class of trade.
AMP
PBM
Manages reimbursement for medications, consultations, and creates and maintains pharmacy retail networks.
Pharmacy benefit manager
PBM
__________________ fees are charges made for every claim processed by PBMs.
Administrative
PBM
Most commonly used benchmark for determining drug pricing.
AWP
PBM
The practice of charging a plan more than the pharmacy reimbursement where PBMs collect the difference.
Spread pricing
PBM
This organization will always set the lowest available prices for brand name medication.
Medicaid
PHARMACY BENEFIT DESIGN AND FORMULARY MANAGEMENT
The amount of the prescription the member pays.
Member cost share
PHARMACY BENEFIT DESIGN AND FORMULARY MANAGEMENT
A pharmacy benefit design that financially rewards patients for using generic and preferred drugs.
Tiering
PHARMACY BENEFIT DESIGN AND FORMULARY MANAGEMENT
The flat fee that a member pays for each of their prescriptions.
Copay
PHARMACY BENEFIT DESIGN AND FORMULARY MANAGEMENT
Members can receive an initial dose at a retail pharmacy but, will be penalized if they don't switch to mail after the first few fills.
Mandatory mail
PHARMACY BENEFIT DESIGN AND FORMULARY MANAGEMENT
Requires review and approval prior to being "covered."
Prior authorization
PHARMACY BENEFIT DESIGN AND FORMULARY MANAGEMENT
A list of drugs that are covered by insurance and details of how those drugs are covered.
Formulary
PHARMACY BENEFIT DESIGN AND FORMULARY MANAGEMENT
This allows a limit to be placed on medications to make sure proper usage of dosage forms and can implement management of maximum daily dosages.
Quantity limits
PHARMACY BENEFIT DESIGN AND FORMULARY MANAGEMENT
Can be set up with a PBM to have the computer system look for required drugs to use prior to coverage of requested agents.
Step therapy
PHARMACY BENEFIT DESIGN AND FORMULARY MANAGEMENT
The percent a member pays of the total ingredient cost.
Coinsurance
MTM, ADHERENCE, AND VALUE BASED CARE
A system that pays for better health outcomes, not just for each service provided.
Value based care
MTM, ADHERENCE, AND VALUE BASED CARE
Creates quality measures for health plans.
National Committee for Quality Assurance (NCQA)
MTM, ADHERENCE, AND VALUE BASED CARE
Runs federal programs focused on improving care quality.
The Center for Medicare and Medicaid Services (CMS)
MTM, ADHERENCE, AND VALUE BASED CARE
Produces research and quality measures to help improve healthcare.
The Agency for Healthcare Research and Quality (AHRQ)
MTM, ADHERENCE, AND VALUE BASED CARE
Develops methods to make care safer and better.
The Institute for Healthcare Improvement (IHI)
MTM, ADHERENCE, AND VALUE BASED CARE
A care model that focuses on personalized, coordinated, and preventive primary care.
Patient Centered Medical Home (PCMH)
MTM, ADHERENCE, AND VALUE BASED CARE
A group of doctors and hospitals that work together to improve care quality and control costs.
Accountable Care Organization (ACO)
MTM, ADHERENCE, AND VALUE BASED CARE
A single payment that covers all services for a specific treatment or condition.
Bundled payments
MTM, ADHERENCE, AND VALUE BASED CARE
A payment model where providers receive a fixed amount per patient, regardless of the number of services given.
Capitation
MTM, ADHERENCE, AND VALUE BASED CARE
Fees that reduce the final payment pharmacies receive, based on their performance.
DIR fees
PBM CONTRACTING
A third-party administrator of prescription drug programs for health plans.
Pharmacy Benefit Manager (PBM)
PBM CONTRACTING
A post-sale payment from a manufacturer to a PBM or plan sponsor, often tied to formulary placement.
Rebate according to PBM contracts
PBM CONTRACTING
A list of medications covered by a health plan.
Formulary
PBM CONTRACTING
When the PBM bills the exact amount it reimburses the pharmacy, without keeping any spread.
Pass-through pricing model
PBM CONTRACTING
Ensuring the plan's pharmacy benefit complies with Medicare (CMS) regulations and reporting requirements.
Service provided by a PBM to support Medicare Part D plan operations
PBM CONTRACTING
Tier of drugs with the highest patient cost-sharing in a Medicare Part D formulary.
Tier 5 - specialty drugs
HOSPITALS AND INPATIENT CARE
Publicly owned hospitals can be owned by federal and _______________ governments.
state
HOSPITALS AND INPATIENT CARE
Physician-owned hospitals are typically what type?
Specialty
HOSPITALS AND INPATIENT CARE
_______________ is required for government reimbursement for provided services.
Accreditation
HOSPITALS AND INPATIENT CARE
A not-for-profit hospital requires _______________ of revenue in the organization.
reinvestment
HOSPITALS AND INPATIENT CARE
Medications as part of hospitals' costs is typically not considered what?
Fixed
HOSPITALS AND INPATIENT CARE
Lack of appropriate _______________ in the community was also one of the top issues for hospital CEOs.
programs
HOSPITALS AND INPATIENT CARE
Hospitals are accredited by the ____________________.
Joint Commission
HOSPITALS AND INPATIENT CARE
Compared to the floor-stock distribution model, in the unit dose model, pharmacists are _____________ involved in reviewing orders.
more
HOSPITALS AND INPATIENT CARE
The least common type of hospital.
Children's
HOSPITALS AND INPATIENT CARE
The top issue for hospital CEOs is ______________________ challenges.
workforce
HOSPITALS AND INPATIENT CARE
The maximum number of days billable for an inpatient stay.
Thirty (30)
HOSPITALS AND INPATIENT CARE
This type of hospital is typically state-owned.
County
HOSPITALS AND INPATIENT CARE
Who implements the board of trustee's policies in a hospital?
Administrators
HOSPITALS AND INPATIENT CARE
Hospitals can be classified by what?
Number of beds
HOSPITALS AND INPATIENT CARE
Many skilled nursing facilities are ______________ funded.
publicly
HOSPITALS AND INPATIENT CARE
The floor-stock distribution model used _____________ dispensing.
non-pharmacist
HOSPITALS AND INPATIENT CARE
The pharmacy and therapeutics committee manages what?
Formulary
HOSPITALS AND INPATIENT CARE
Between 1980 and 2015, the presence of what type of hospital has greatly declined?
Not for profit
HOSPITALS AND INPATIENT CARE
A long-term care pharmacy services likely includes preparation of what?
Infusions
HOSPITALS AND INPATIENT CARE
A hospital's board of trustees may examine what type of trends, relative to the facility's goals?
Long term
CONTRACTING AND REBATES
The manufacturer gives the rebate to who?
PBM
CONTRACTING AND REBATES
PBM pays the pharmacy for a submitted brand or generic drug claim and that is different, often lower than the price paid by the plan sponsor to the PBM.
Spread
CONTRACTING AND REBATES
What type of company enters into a contract with a PBM for clinical and operational support?
Health plan