Safe

Effective

Patient-Centered

Timely

Efficient

Equitable

*STEEEP*

PRO

(Patient-Reported Outcomes)

-measure quality of life, patient satisfaction, adverse effects, and effectiveness of therapy

1. Health Belief Model

2. Transtheoretical Model of Change

3. Theory of reasoned action and Theory of planned behavior

4. Social cognitive theory

5. Locus of control

economics

-asks what, how, and who will produce

Land (natural resources)

Labor

Capital (machines, buildings, etc.)

NOT MONEY!

Income

Tastes and preferences

Number of consumers

Consumer expectations

Price of related goods

*Price changes quantity demanded

Technology

Resource costs

Prices of alternative outputs (cross price)

Number of sellers

Seller expectations

*Price changes quantity supplied

e>1

e=1

e<1

elastic (flatter curves - small increase in price, greater decrease in quantity demanded)

unit elastic

inelastic (curves more vertical - greater increase in price, less decrease in quantity demanded)

Determinants of Elasticity

*inelastic

*elastic

*inelastic: short-run, few substitutes, low price relative to income, broadly-defined market, necessities

*elastic: long-run, many substitutes, high price relative to income, narrowly-defined market, luxury goods

income elasticity >0 is referred to as a _________ good while <0 is referred to as a _________ good.

number of buyers and sellers

barriers to entry or exit

product differentiation

full information

change in an individuals' behavior resulting from reduction in risk (i.e. using too much health insurance, engage in risky behavior, forego preventative care) is known as what?

moral hazard

elimination (exclusionary) periods

limits to amounts paid for certain covered events

exclusion of coverage for certain events (i.e. elective surgery, hazardous activities)

coinsurance

co-payments

deductibles

caps

prior authorizations

gatekeepers

tiered formularies

(tier 1 = generic, tier 2 = brand; no generic available, tier 3 = brand; generic available; high copay; not preferred)

contract with pharmacies

maintain formularies

conduct drug utilization reviews

process claims

reimburse providers

control costs and utilization

fee-for-service (FFS)

-patient retains choice of provider, but it is expensive to process claims and there is no incentive to control utilization or cost

HMOs: often place providers directly or indirectly at risk (capitated payment), usually do not cover out-of-network care, "gatekeepers" coordinate and authorize medical services, and often utilize lower-cost providers (i.e. nurse practictioners) as gatekeepers

PPOs: not risk-bearing, groups of affiliated providers who contract plans, generally have non-exclusive contracts, patient incentive to see network providers (only some coverage out of network), and discounted FFS payment

1. enforce property rights (public health - i.e. vaccinations, safety and professional rights - i.e. licensure, regulation)

2. correct market failures (barriers to entry, imperfect information, product differentiation, few sellers)

state government

-local is more population based (i.e. health needs assessment, disease surveiliance, emergency transportation, health insurance, and health & food safety)

-both state and local oversee public health screenings

Match the following types of Medicare with their function:

A, B, C, D

1. Supplementary medical insurance (SMI), outpatient

2. Prescription drug benefit

3. Hospital insurance (HI), skilled nursing facility, hospice, and home health care

4. Medicare + Choice, Medicare Advantage (managed care organizations - provide all benefits except hospice)

1. B

2. D

3. A

4. C

1. person and/or spouse worked for at least 10 years in Medicare-covered employment

2. citizens or permanent residents of the US

 3. at least 65 years old

4. others under 65: disabled and end-stage renal disease patients

false

-25% coinsurance is good for the next $2,000 then there is 100% coinsurance for the next $2,850 ("donut hole"). After this period has been met, there is a 5% copay OR $2 generic co-pay and $5 brand co-pay.

Part A - HI trust fund: payroll tax + cost sharing

Part B/D - SMI trust fund: general revenues + premiums + cost sharing

Match the following with the correct Medicaid group (all are Mandated Categorically Needy):

(A) Group 1

(B)Group 2

(C) Group 3

(D) Group 4

 1. Poor with children - limited family income and resources/dependent child without parental support or care

2. Qualified Medicare Beneficiaries (QMBs) - Medicare-eligible individuals with incomes below FPL and limited assets (Medicare pays premiums and other expenses)/or incomes between 100-120% FPL (Medicaid pays Part B deduct. only)

3. Supplemental Security Income (SSI) recipients - elderly, blind, or disabled (eligibility based on income and assets)

4.  Pregnant women and all children <19 years in families with incomes at or below FPL

1. A

2. C

3. B

4. D

true

-must include pregnant women and children under 18

-can include children under 21, parents and other caretaker relatives, elderly, and disabled

-medical expenses must be such that effective income meets the state threshold ("spending down")

-inpatient and outpatient hospital services

-physician, midwife, and certified nurse practitioner services

-x-ray and lab services

-nursing home and home health care 21+

-early and periodic screening, diagnosis, and treatment (EPSDT) for children under 21

-family planning services and supplies

-health clinics/health centers

-states may receive funds for optional services such as prescription drugs, prosthetic devices, hearing aids, vision and dental care, and transportation

true

-providers can only charge the Medicaid-approved amount (no balance billing) and agree to be paid by Medicaid

1. mandating employer-paid health insurance - "pay or play": either "pay" a fee to the state to provide insurance for their employees or "play" by providing coverage themselves (small firms and part-time employees exempt)

2. expanding Medicaid to cover more of the uninsured - authorized and funded at federal levels, states design and implement (ex: SCHIP)

3. provide tax credits for low-income individuals to buy insurance- least effective

Medicare Modernization Act

-under Medicare Part D

One type of health reform involves where states create a pool of funds from taxing private-pay hospital bills or from general tax revenues to hospitals who deliver uncompensated care to low-income individuals (uncompensated care pools).

T/F: This type of reform would increase access of healthcare to individuals

false

-this would not increase access per se, but might make uncompensated care more available and keep "safety net" hospitals open

1. Intellectual Property Protection (IPP) - patents (good for about 20 years) and exclusivity (no one else can produce for 6 months on the market)

2. Research & Development (R&D) - product life cycles, blockbuster products (sell $1 billion/year, ideal product, widely used), and marketing in place of innovention

3. Profitability - net profit as a percentage of revenue, mean return on investment, and "virtuous rent seeking models"

1. Research-oriented chemical firms

2. Biotechnology or biopharmaceutical firms

3. Generic firms

1. Economic: pricing and price differentials (within the US and compared to other countries)

2. Science/technology: R&D investment (who should do R&D, etc.)

3. Socio-political: market prospects

Expenses to a pharmacy include what?

Which of these make up 2/3 of a pharmacy's expenses?

products, labor, expenses directly related to the pharmacy, expenses shared across all departments within the retail unit

the product - inventory

What was the average cost of a prescription in 2006?

What percent of this cost relates to the manufacturer, wholesaler, and pharmacy?

about $68

manufacturer: 78%

wholesaler: 3%

pharmacy: 19%

price makers: free to set price, constrained by competitors (i.e. manufacturers, wholesalers, insurance firms)

price takers: accept price offered, manufacturers in countries with price controls (i.e. dispensing pharmacies)

FFS system - revenue generator (revenue increases as the number of products and services increase)

Fixed payment system - cost center (revenue fixed; costs increase as products and services increase)

drug therapy problem

-occurs when a problem does not obtain therapy (access), has ineffective therapy, inadequate dose, nonadherence (effectiveness), takes the wrong dose, overdoses, has an adverse reaction (safety), etc.

Medication Therapy Management - provides services that will optimize therapeutic outcomes for targeted beneficiaries; are independent of but can occur in conjunction with the provision of a medication product

Beneficiaries include individuals who have multiple chronic diseases (>3), who are taking multiple covered drugs (>6), and are likely to incur annual costs that exceed a defined minimum of $4,000

-prescribing, dispensing and advising, consumption

-prospective (clinical) DUR

-retrospective (educational) DUR

-therapeutic outcomes monitoring

-performance management (aka clinical governance)

Match the following with the correct answer. Which of the following a primary experience?

A. disease B. sickness C. illness

1. a person's experience of not being well

2. an inference based on interpretation of subjective and objective data

3. refers to behavior; inability to meet obligations or engage in desired activities (i.e. work or social events); related to quality of life

-patients' experiences

-the "microsystems" that give care (i.e. providers, pharmacists, etc.)

-the organizations that house and support microsystems (i.e. hospitals, etc.)

-the environment of laws, rules, payment, accreditation, and professional training that shape organizational action

qualifications: post PharmD training 1-2 years, board certification, and want responsibility

job duties: rounds with medical teams, obtain medical histories, provide discharge counseling, manage adverse drug reaction programs, and respond to drug information questions

Which of the following is/are covered by Medicare Part A?

A. hospital care

B. skilled nursing facility services

C. hospice

D. all of the above

E. only A & B

Channels of legal distribution of prescription drugs include(s):

A. drug wholesaling

B. direct from the manufacturer

C. drug diversion

D. A & B

E. all of the above

The vast majority of prescription drug products that are used in the US flow through?

A. mail order

B. hospitals

C. outpatient settings

D. nursing homes

a law enacted by Congress that limits the amount of time a preexisting condition may be excluded from coverage to one year, requires insurance companies to sell health insurance policies to small employers and individuals who lose coverage without regard to their health history, requires insurance companies to renew policies they sell to groups and individuals, and outlines standards for patient confidentiality.