HCUS 3700 Exam 2

Pharmacy Benefit Manager (PBM)

middlemen between drug manufacturers, pharmacies, insurance companies, and patients.

What do PBMs do?

• negotiate lower drug prices on behalf of insurance companies

• negotiate rebates with drug manufacturers to create formularies (in-network drugs)

How do PBMs make money?

through spread pricing; PBM charges a health insurance company more for a prescription drug than it actually pays the pharmacy.

Incentivized

Higher cost drugs on formulary (bigger price = bigger margins)

What are the 3 Medical Device Categories?

• Class I- low risk (no testing, only required to register)

• Class II- intermediate risk (some testing)

• Class III- high risk (rigorous testing)

Pharmaceuticals

• Discovery- basic research

• Development- pre-clinical, clinical trials, phases I-III

• Delivery

What is the iron triangle?

3 major considerations around a nation’s health care system

3 components of the iron triangle

1) Access to health care goods and services

2) Quality of the health care provided (health outcomes and factors related to those health outcomes)

3) Cost: $$ spent on health care within the US

What are The 5 A’s of Access

1) Availability

2) Accessibility

3) Accommodation

4) Affordability

5) Acceptability

1) Availability

• Does provider have adequate number of personnel?

• (ex: If too few doctors, it will be difficult to get on the schedule) Are necessary services provided in the area – specific medical equipment/procedures, specialists?

2) Accessibility

• Geographic accessibility (distance from home/work)

• accessibility of the physical space.

• Can patient reach provider conveniently?

3) Accommodation

• Do business hours fit patient needs? Walk-ins welcome? Established patient?

4) Affordability

• What are the patient’s out-of-pocket costs for care?

5) Acceptability

• The fit between patient and provider attitudes and the provider/practice characteristics.

• Provider gender.

• Patient/Provider attitudes

• Language barrier. Insurance coverage (from the provider’s perspective)

What makes the US an outlier?

Medical Model of Health Care Delivery (Curative care)

• Increase in Elderly Population

• Defensive Medicine

• Growth of Technology

• Fraud and Abuse

• Prices

• Imperfect Market

Third-Party Payment: insurance companies pay the majority of health care costs rather than consumers

• Individual out-of-pocket costs are much lower than the actual cost of services (part of an imperfect market

Multipayer System: Medicare, Medicaid, Etc

• administrative cost

Cost:

Total $$ spent on health care goods and services within a

country

• Access:

Ability to obtain needed health care goods and services

Quality

• track quality

• financial incentive to improve outcomes

How might high or low costs impact access?

• High costs: Decrease access because people may struggle to afford healthcare, causing them to delay or avoid necessary treatment.

• Low costs: Increase access by making healthcare more affordable and allowing more people to receive necessary care.

How might increased or decreased access impact quality?

• Increased access: Can improve quality by allowing more people to receive preventive care, early diagnoses, and timely treatment. However, it could lower quality if healthcare facilities become overcrowded or understaffed.

• Decreased access: Can lower quality because patients may delay treatment, leading to more serious health problems and worse outcomes.

How might better or worse quality impact cost

• Better quality: May increase costs initially due to better technology, staff, and treatments, but can lower long-term costs by preventing complications and hospital readmissions.

• Worse quality: May lower costs initially, but can increase long-term costs due to medical errors, complications, and repeated treatments.

what are the 5 SDOH

• Health care quality and access

• Social and community context

• Economic stability

• Neighborhood and built environment

• Education access and quality

Economic Stability

• Help people earn steady incomes that allow them to meet their health needs

• Employment and Income

Education Access and Quality

• increase educational opportunities and help children and adolescents do well in school.

• Safe and quality childcare and early childhood education

• Language and literacy

Social and Community Context

• Increase social and community support.

• Social Support Network

• Culture

• Discrimination and bias

Neighborhood and Built Environment

• Create neighborhoods and environments that promote health and safety

• Housing

• Neighborhood

• Food deserts

Health Care Access and Quality

• Increase access to comprehensive, high-quality health care services

Health Care Reform:

• aims to improve all 3 aspects of the iron triangle (usually can pick 2)

• poor performance areas are target for reform

• no single solution

Why does access matter?

Can lead to:

• lower life expectancy

• frequent hospitalizations

• higher treatment costs

• health complications

Barriers to access

1) High cost of care

• Inadequate or no insurance coverage

• cost barrier leads to delays in care

2) Lack of availability of services

• “Availability”

3) Lack of culturally competent care

• “Acceptability

How would high cost impact the other aspects of the iron triangle?

( Access and Quality)

• Access: High costs make healthcare less affordable, causing people to delay or avoid necessary medical care.

• Quality: High costs can limit resources available for patient care, potentially lowering the quality of services.

Donabedian Triad

Used to measure health care quality

• outcome (results), process (care), structure (tools)

Clinical Practice Guidelines

Protocols that help to standardize care for certain conditions

Critical Pathways

Coordinate collaboration in a patient’s care across multiple health care disciplines

Health Care-Associated Infections

Steps taken by hospitals and health systems to help prevent medical errors. More

on this next session

Cost-Efficiency

Payment models incentivize efficient care that leads to improved patient outcomes

MIPS

Merit-based Incentive Payment System

• Health care providers report their quality measures to Medicare and are financially incentivized to demonstrate high quality care

Electronic Medical Record

Single practice’s version of the medical chart.

• Contains documentation on care patient received in that setting

Electronic Health Record

Health system’s version of the medical chart.

• Contains info and patient care notes from across multiple providers in the health system (primary care, specialist, surgeon, etc)