1.  Define Cost effectiveness analysis (CEA)

2.  Goal of CEA

3.  Equation

4.  Contrast with CBA

1.  An analysis tool that contrasts the costs of alternative medical interventions relative to a difference in a single medical outcome

2.  Provide summary information that contrasts cost and effectiveness that can help decision-makers

3.  CE ratio = (expected cost tx - expected cost alternative) / (expected health improvement tx - alternative)

4.  CE ratio does not yield answer unlike CBA, but a cost to obtain a unit of improvement.  Decision maker selects treatment over alternative if he/she values health improvement more than cost to achieve health improvement

Denominator CEA if

1.  Good health outcome

2.  Bad healthoutcome (ie, mortality rate)

1.  Expected health outcome of tx - expexted health outcome alternative

2.  Expected health outcome alternative - expected health outcome treatment

1.  Higher cost of treatment with better outcome

2.  Lower cost of treatment with worse outcome

1.  Better treatment at lower price

2.  Worse treatment at higher price

1.  Most powerful is CBA

2.  Cost-utility analysis can also be used

1.  Control chemical use in the workplace

2.  Control emissions of chemicals from factories/other sources

3.  Affect public perception of chemical risks 

1.  US EPA

2.  OSHA (Occupational Safety and Health Administration)

*Determine concentration of chemicals in air, water, soil, food, and consumer products that are safe and/or minimal risk

1.  Who does OSHA protect?

2.  How...ie, what is the major thing they promulgate?

3.  How many of #2 are there?

1.  Workers from excessive exposure to chemcials in the workplace

2.  Permissible exposure limits (PEL):  maximum amount or concentration of a chemical that a worker may be exposed to

3.  300 chemicals are regulated by PELs

8-hr PEL for the following chemicals

1. Asbestos

2.  Benzene

3.  EtOH

4.  Lead

5.  Oil mist

1.  0.1 f/mL

2.  1 ppm

3.  1000 ppm

4.  50 ug/m3

5.  5 mg/m3

OSHA Areas of Regulation and subsections of each

5 exposures and 1 lack of

Exposures:

1.  Hazardous chemicals:  MSDS, respiratory protection

2.  Blood borne pathogens

3.  Eyes or body to corrosive materials:  first aid

4.  Wet surfaces and potential slips and falls

5.  Latex allergy

1.  Lack of personal protective equipmen (PPE), hand protection, eye and face protection

1.  No specific policy on open-heeled shoes, but policy on protective footware in general

2.  Without a previously menthioned hazard, Crocs are between labor-management negotiations which OSHA does not participate in

OSHA on Compounding

3 examples on which OSHA has issued a technical information bulletin

1.  Custom anticancer drugs such as ointments with busulfan

2.  Compounded hormone forms d/t hormone exposure

3.  ABX such as penicillin which there is a large allergy risk to

1.  Pesticide use

2.  Industrial chemicals released into environment

3.  Chemical pollutants in drinking water supplies

4.  Hazardous waste disposal

5.  Toxic pollutants in water and air

Acceptable daily intake 

*For all toxic effects

No observed adverse effect level

*Determined by animal testing

Reference dose (equivalent to ADI)

*dose that a person could receive daily for an entire lifetime without an increasedrisk of adverse health effect

Important thing to remember with risk probability for chemical carcinogens

1.  Sources

2.  Pathways

3.  Monitoring

4.  Populations

1.  OSHA:  Water exposure

2.  FDA:  Food additives, drugs, medical devices

3.  US EPA:  Pesticides and drinking water

1.  Identification of chemicals of potential concern

2.  Exposure

3.  Toxicity

4.  Risk Characterization

5.  Uncertainty analysis

1.  Identificaiton of a set of chemcials of potential concerns (likely site related)

2.  Identificaiton of data of sufficient quality for use in qualitative risk assessment

3 components of exposure assessment

1.  Characterization of exposure pathways:  setting (climate, vegetation, groundwater, locaiton of surface water)

2.  Identification of exposure pathways to the greater population

*Sources, releases, types, locations of chemical sites and locations of potentially exposed populations

3.  Quantification of exposure:  magnitude, frequency, duration is estimate (concentration/intake)

1.  Manage workplace and environmental risks

2.  Air and water discharges

3.  Approving new medications

4.  Public health events that include pharmacy's involvement 

"The science and art of healping people change their lifestyle toward a state of optimum health.  Lifestyle change can be facilitated by a combination of efforts to enhance awareness, chagne behavior, and create environments that support good health practices"

"Any combination of health education and related organizational, economic, and environmental supports for behavior of individuals, groups, or communities conducive to health"

"The activity undertaken by individuals for hte purpose of maintaining or enhancing their health, preventing health problems, or achieving a positive body image"

"Those personal attributes such as beliefs, expectations, motives, values, perceptions, and other cognitive elements; personality characteristics, including affective and emotional states and traits; and overt behavior patters, actions, and habits that relate to health maintenance, to health restoration, and to health improvement."

1.  Preventative Health Behavior

2.  Illness Health Behavior

3.  Sick Role Behavior

An ill individual engages in illness behavior when he or she engages in activity to:

1.  Define the state of health

then

2.  Discover a suitable remedy

*Mediated by strong subjective interpretations of the meanings of symptoms...ie, chronic joint pain you may take chondroitin...taking an arrow to the knee may cause you to seek ER tx

Person engage in activities for purpose of getting well:

1.  Sick person is freed/exempt from carrying out normal societal roles b/c they are not responsible for their plight

*Must be temporary with person actively trying to get well and there is a social compact that the pt seek competent help and cooperate with medical care

1.  Sick person freed or exempt from carrying out normal social roles (more severe = more freedom from responsiblity)

2.  Ppl in sick role not directly responsible for plight

3.  Sick person needs to try to get well

4.  Sick person must seek competent help and cooperate with medical care (compact with physician so the function of the physician is one of social control)

Healthy People 2000 and 2010

1.  Define LHI

2.  What are the 10 for health people

1.  Leading health indicators

2.  Physical activity; overweight and obesity; tobacco use; substance abuse; responsible sexual behavior; mental health; injury and violence; environmental quality; immunization; access to healthcare 

Consumer Health Education

1.  Define high quality health information

2.  2 factors that can affect the delivery of health education are:

1.  Accurate, current, valid, apprpriate, intelligible, and free of bias

2.  A)  Socioeconomic status

B)  Education level

Health Literacy

1.  What it incorporates as far as range of abilities (4)

2.  Extends also to:

1.  A)  to read, comprehend, and analyze information

B)  Decode instructions, symbols, charts, diagrams

C)  Weigh risks and benefits

D)  Make decisions and take actions

2.  Materials, environments, and challenges specifically associated with disease prevention and health promotion

Application of commercial marketing technologies to the anlysis, planning, execution, and evaluation of programs designed to influence the voluntary behavior of target audiences in order to improve their personal welfare and that of their society

*Uses research to group target audience with common risk behaviors, similar motivations, and channel preferences

1.  Product:  what behavior the consumer is asked to buy into

2.  Price:  what the consumer must give up in order to obtain the product

3.  Place:  how and where the product reaches the consumer

4.  Promotion:  how informaiton about the product is disseminated

1.  Must make sure you have enough of everything

2.  Check to make sure that ppl, systems, and materials are meeting quality expectations

Prevention Programming

1.  Name and define 2 models

1.  Stage-based:  precontemplation, contemplation, preparation, action, maintenance

2.  Precede-Proceed Model:  The precede component of the model includes predisposing, reinforcing, and enabling constructs.  The proceed component of the model includes policy, regulations, resources, and organization

1.  Precontemplation:  no acknowledgement behavior needs changed

2.  Contemplation:  Acknowledge problem, but not sure you want to change

3.  Preparation

4.  Action

5.  Maintanence 

Precede-Proceed Model

1.  Where is it used?

2.  What diciplines involved (4)

1.  Health promotion and disease prevention research projects, education programs, and community applications

2.  Epidemiology

Social/behaviorla theory

Educational sciences

Health administration

Precede-Proceed Model 

1.  Precede

2.  Proceed

1.  Predisposing, reinforcing, enabling constructs in educational diagnosis and evaluation

2.  Policy, regulatory, and organizational constructs in educational and environmental development

1.  Social diagnosis

2.  Epidemiological diagnosis

3.  Behavioral/Environmental diagnosis

4.  Educational/organizational diagnosis

5.  Administrative/policy diagnosis

6.  Implementation

7.  Evaluation

Precede-Proceed Evaluation

1.  Most often associated with ideas of determining:

2.  Summative evaluations

3.  Formative evaluations

1.  accountability, assessing value, and determining growth

2.  Those evaluations conducted to determine if programs are to be supported or terminated

3.  Differe from summative in that formative are conducted with a primary purpose of assisting in program improvement.  The purpose of formative evaluation is to provide feedback

The Evaluation Cycle

1.  When are summative and formative used?

2.  Needs assessments

3.  Logic models

4.  Process evaluations

5.  Outcome and impact evaluations

1.  Formative early in a program and summative later stages

2.  Help identify nature and scope of problem

3.  Used in program development and for reviewing program content and theory

4.  Document the kinds and amounts of services provided and the characteristics of the program and its participants

5.  Assess the results of the program and short-term and long-term effectiveness

Training sessions, educational materials

Efforts to describe and document program staff, participants, and activities during the operation of the program

Routine data collected

Fidelity assessment:  has the program been faithfully applied

Outcome and Impact Evaluations

1.  What they find

2.  What type of research methods are emphasized?

1.  Degree to which a program or policy has produced changes at individual, organizational, or community levels

2.  Quantitative research methods

Integration of Health Belief Model

1.  Percieved susceptiblity

2.  Perceived severity

3.  Perceived benefits

4.  Cues to action

5.  Self-efficacy

1.  Opinions of one's chances of being at risk

2.  One's perception of the severity of the particular condition

3.  One's belief on the impact of the benefit of avoiding or reducing risk

4.  Strategies used to activate readiness

5.  Confidence in one's ability to take action

1.  Chose target audience(s)

2.  Set objectives that are measurable

3.  Chose message and means of delivery

4.  Evaluation to provide evidence of how successful the program has been

Public Health and Changes in the Law

2 Examples

1.  Effective strategies in area of smoking

2.  Motor vehicle death reductions

PA's

1.  In 1990 how many accreditied programs and students accepted annually

2.  In 1996

3.  in 2002

1.  51; 26

2.  89; 40

3.  132; 36

WV Med Practice Act PAs

1.  What can they not prescribe?

2.  What supply of schedule III?

3.  What must they do to be eligible for prescription privaleges

4.  What must they do to maintain prescription privaleges

1.  CI/II; anticoagulants, antineoplastics, radiopharmaceuticals, general anesthetics, radiographic contrast materials

2.  72 hr supply without refill

3.  Pt care for min of 2 yrs and immediately preceding submission to board of the job description containing prescription privileges...sucessful accredited course of instruction in clinical pharmcology approved by board

4.  Maintain National Certification as a PA and  complete 10 hrs of CE in rational drug therapy each period

*Nothing shall be construed as permitting independent prescription by a PA

1.  How many currently practicing PAs?

2.  How many yearly graduates?

3.  How many accredited programs now, and in the next 4-5 yrs?

4.  How many applicants per spot in each class

1.  84,000+

2.  6,000

3.  160 now with 40-50 starting in next 4-5 yrs

4.  3 for every one seat

1960s PAs vs Today

1.  Experience

2.  Academic background

3.  Age of matriculants

1.  1960:  high; today: low

2.  1960 less; today: more

3.  1960 older; today: younger

1.  Decision-making skills

2.  Problem solving

3.  Self-reflection

4.  Feedback on performance

5.  Growth beyond entry level

1.  PGY1 does not specialize but may focus (ambulatory care); manage and improve medication use process; evidence based care; interdisciplinary teams; leadership; management skills

2.  PGY2 specializes

Accreditation

1.  Pre-candidate

2.  Candidate

3.  Conditional

1.  Have submitted application stating they are starting and are recruiting first residents

2.  Started residency program and recruited first resident

3.  Have been reviewed and may not meet all criteria and risk losing accreditation

Staffing during residency

Salary

1.  Staffing set by program but must meet ACGME duty hour guidelines

2.  Stipend, benefits, may defer loans, vacation days

1.  Enhance clinical skills

2.  Develop and implement various patient care programs

3.  Enhance leadership skills

4.  Networking opportunities

5.  Teaching opportunities

6.  Participate in research

1.   Work environment

2.  Residency projects

3.  Competition

4.  Pt demographics and services offered

5.  Teaching component

6.  Staffing commitment

7.  Accreditation

1.  Advanced training with direct patient care opportunities

2.  Preparation to become a leading in pharmacy practice

3.  Development and implementation of pt care services

*Focus is on MTM, collaborative drug therapy, immunization, and health screenings

1.  Partnership with SOP

2.  Independent program run by community pharmacy chains

3.  Independent programs-SOP with own pharmacies

1.  Who had first prescription drug plan?

2.  % of prescriptions payed by some sort of health insurance 1970 vs 2010

1.  United Auto Workers through Blue Cross (1969)

2.  <12%; 95%

1.  Patient

2.  Healthcare Provider

3.  Payer (3rd party)

3rd Party Process for companies desiring to provide prescription coverage

1.  Manage a Self-insured Program

2.  Employ a fiscal intermediary

1.  Large sum of money in escrow to pay for claims; not desirable to most companies d/t risk and cash being tied up in escrow

2.  These companies provide underwriting and/or administrative servies to cover costs of health benefits-most will purchase reinsurance d/t risk (BCBS)

PBMs

1.  Define

2.  Example companies

3.  Responsibilities (5)

1.  3rd party administrators specifically for prescription drug programs

2.  Caremark, Medco, Express Scripts

3.  Processing and paying benefits; Developing and maintaining formulary; Contracting with pharmacies; Negotiating discounts and rebates with drug manufacturers; Controlling costs via various methods

1.  Premiums paid by beneficiaries

2.  Deductables

3.  Co-pays for services (tiered to encourage generic usage)

4.  Prior authorization (PA)

5.  Step therapy programs

6.  Non-covered products/services

7.  Quantity limits

8.  Maximum benefit

1.  Loss from not participating (dec volume)

2.  Loss from participating (decreased profit per prescription)

-most states mandate Medicaid never pay more than lowest payer

Differential analysis

1.  What is it?

2.  Other considerations

1.  Basic cost analysis based on different reimbursement proposals

2.  Excess income can pay fixed costs, other insurers may demand lower cost with next contract; do not want to accept too many low reimbursement plans; excess volume could impact quality

1.  What does CMS stand for?

2.  Parts of Medicare (4)

1.  Centers for Medicare and Medicaid Service:  for those >65 yo or <65 yo with disability or ESRD

2.  Part A:  hospital (no premium)

Part B:  Medical for outpatient (99.90 monthly premium + 140 annual deductable

Part C:  Advantage plans covering costs not met by A and B (co-pays, deductibles), vision, dental, drugs, (private ensurers at various costs)

Part D:  prescription drug offered by privary insurers at varing costs

Medicare Part D

1.  Act that created it

2.  Annual enrollment period

3.  Premium and deductible WV

4.  Total drug spending before gap reached

5.  Gap lasts until what?

6.  % pt pays for generics; brands

7.  Catastrophic coverate brand/generic

1.  Medicare Prescription Drug Improvement and Modernization Act (MMA) of 2003

2.  Oct 15-Dec 7, 2012

3.  $28.70/month premium; $325 deductible

4.  $2970

5.  $4750 (Gap closed by AHA in 2020)

6.  79% generic and 47.5% brand

7.  Generic:  pt pays greater of 5% or 2.60 co-pay

Brand:  pt pays greater of 5% or 6.50 co-pay

Medicaid

1.  Who funds it?

2.  Usual co-pay

3.  1972 vs 2004 expenditures

1.  Fedearl and state so eligibility varies state to state

2.  $0.50 to $3

3.  <10 billion; >300 billion

Impatc of Health Insurance on Rx

1.  Decline in pharmacies gross margin 1986-2008

2.  How long does medicare part D often take to reimburse?

3.  How long do wholesalers usually wait for payment?

1.  32.2% --> 23.2%

2.  3-6 weeks

3.  15 days

Wholesaler acquisition cost

-List price for what manufacturers charge drug wholesalers without discount or incentive reductions in price

Average wholesale price

-List price for what drug wholesalers charge pharmacies 

Includes no discounts or reduction in price 

*originally good estimate of AAC, but slowly being phased out of use

*Typically set 20-25% above true WAC

Average sale price

-Based on manufacturer's avg selling price including all rebates, prompt payment discounts, and volume discounts

*replaced basis of payment for part B covered medications (per MMA)

Average manufacturer's Price

*Reflects all discounts given to purchaser

Maximum Allowable Cost

*max cost that the 3rd part will pay for multisource drug

Avg of generic price from manufacturers 

Trends in payment

1.  What percent lower is ASP than AWP?

2.  ASP is a ___ weighted average so who is adversely impacted

1.  49%

2.  Volume; pharmacy that pays above average is adversely impacted

2005 Deficit Reduction Act

1.  AMP based pricing __% below true AAC

2.  If AMP reimbursement fully implemented, what % of community pharmacies will close?

1.  30%

2.  20%

2008 Medicare Improvements for Pts and Providers Act (MIPPA)

1.  What did it do?

1.  Established temporary moratorium on AMP-based pricing structure and this has been extended eveyr year since

*debate continues on acceptable payment methods

The extent to which a person's behavior corresponds with the agreed recommendations from a health care provider

*80-120% of doses recommended

1.  Meds

2.  Lifestyle adjustments

3.  Treatment guidelines

4.  Study protocol

5.  Office visits

# of days medicine supply / # of actual days b/t refills

*>1 indicates pt has too much medication

<1 = pt has half the supply needed

Nonadherence costs

1.  What risks increase as MPR increases?

2.  Difference in disease related cost adherent vs nonadhereant

1.  Hospitalization risk decreased for patietns with DM and HTN

2.  Nonadherence (0-19% MPR) have almost double the costs

1.  When can good adherence increase mortality risk?

2.  When is adherence associated with lower mortality (2)

1.  Good adherence to harmful drug txx

2.  Benficial drug OR placebo

HBM:  

2 Individual perceptions

1.  Perceived susceptibility to disease

2.  Perceived severity of disease

HBM

3 modifying factors of HBM

1.  Personal variables

2.  Perceived threat of disease

3.  Cues to action

HBM

2 likelihoods of action

1.  Perceived benefits - perceived barriers

2.  Likelihood of health behavior

Nonadherence barriers

1.  3 Behavioral

2.  3 System

1.  Social support

Cognition

Personal beliefs 

2.  Treatment complexity

System complexity

Cost

1.  Internal

2.  External

3.  Chance

1.  Precontimplation

2.  Contimplation

3.  Preparation

4.  Action

5.  Maintanence

Intelligent Noncompliance

1.  What is it?

2.  Why are elderly more likely to do it (3)

1.  Reasons for being noncompliant have a rational basis

2.  Have seen prescribing fads come and go

Seen ineffective/toxic treatments

Learned about their bodies and reactions to drugs over the years

5 Predictors of Poor Adherence with Examples

1.  Patient characteristics:  experiences, values

2.  Disease features:  symptomatic, psych/neurologic

3.  Treatment factors:  duration, expense, sig behavioral change

4.  Environmental factors:  competing priorities/convenience

5.  Practitioner/pt relationship:  empathy, communication, trust

SEAMS

1.  Define

2.  What does it evaluatie (2)

1.  Self-Efficacy for Appropriate Medication Use Scale

2.  Pt plans for how they will schedule and remember to take their meds; Pt confidence in their ability in different circumstances

Morisky Medicaiton Compliance Scale

1.  What does it test

2.  4 Y/N questions

1.  Knowledge and motivation of pt

2.  Do you ever forget to take your medication?

Are you caerles sat times about taking yoru medicine?

When you feel better do you sometimes stop taking your meds?

Sometimes if you feel worse when you take your medicine, do you stop taking it?

1.  Questionnaire

2.  State adherence issue in med hx

3.  Make note in allergy field

4.  Pt educaiton, involvement

5.  Accommodate special needs

6.  Appointment structure, reminders

7.  Calenders

8.  Contracts

1.  Pill timer

2.  Talking Rx

3.  Med Light Tablet Organizer

4.  MedGlider pillbox

5.  Newdaycorp pillboxes

1.  Query electronic data

2.  Target pts for time spent

3.  MTM

4.  Collaborative networks

5.  Automatic refill programs

Pharmacy Engagement Programs (McKesson)

1.  Sponsored ___ ___ ___

2.  4 Pharmacy-based programs

1.  Clinical Service Network

2.  Customized

Targeted behavioral coaching sessions

Motivational interviewing

Pt educaiton and reminder programs

1.  MedsIndex

2.  Value-based benefit design

3.  Memotext

Meds Index

1.  Who developed

2.  Score from dispensing software assessing:

3.  What is score used for?

4.  What it makes judgements possible on (2 groups)

1.  Pharmacy Guild of Australia

2.  Quantity prescriber intended: quantity dispensed

3.  To guide aggregate efforts but also to work with individual pts

4.  Individual pts; Aggregate pts groups (by pharamcy, doctor, health plan, clinic)

MedsIndex Scoring

What are the 4 scoring ranges

1.  >85 pt is good

2.  80:  Consider drug administration aid

3.  75:  Mome medication review, see doctor

4.  70 or lower:  Essential to talk with doctor about compliance

Value-Based Benefit Design

1.  ___-____ restructuring of health benfits

2.  ___ focused > ____ focused

3.  Minimizes what?

4.  Addresses what?

1.  Clinically-sensitive

2.  Quality > value

3.  Poor health outcomes

4.  Misalignment of incentives to optimize health care effectiveness, efficiency

Value-Based Benefit Deisgn

1.  What does Value =?

2.  Should adjust patient what?

3.  More ___ beneficial tx is expected to be for pt, ___ cost-share for pt

1.  clinical benefit of money spent

2.  Out-of-pocket costs for health services

3.  Clinically; Lower