1
Q
What is Cost Effectiveness Analysis (CEA)?
A
Compares: Cost and Effect
- cost is money
- effect is something clinical
2
Q
What is Cost Minimization Analysis (CMA)?
A
Compares: Cost vs Cost
- determination is made that all the drugs are the same clinically, therefore compares the cost of each
- clinical equivalence= CMA
3
Q
What is Cost Utility Analysis (CUA)?
A
Compares: cost and outcome
- cost= money
- outcome= quality of life years (QALY); patients well being
4
Q
What is Cost Benefit Analysis (CBA)?
A
Compares: cost and benefit
- cost is money
- benefit is what they plan to gain, usually converted to a dollar amount; government programs or new initiatives
5
Q
What is a deductible?
A
an amount of expense that must be paid out of pocket before an insurer will pay any expenses
6
Q
What is a Co-pay?
A
a fixed payment for a covered service, paid when an individual receives services
7
Q
What is Coinsurance?
A
a percentage of the bill that you pay (assuming that you have no met any deductibles)
8
Q
What is Catastrophic Cap/Limit?
A
the maximum out-of-pocket expense for the patient during a defined period of time
9
Q
What is Tier 1?
A
Preferred generic: this is your lowest-cost tier, low cost preferred generic drugs and some preferred brand drugs
10
Q
What is Tier 2?
A
Generic: this is a lower cost tier, and includes preferred generic drugs and some preferred brand drugs
11
Q
What is Tier 3?
A
Preferred brand: this is your middle-cost tier, and includes preferred brand drugs and non-preferred generic drugs
12
Q
What is Tier 4?
A
Non-preferred brand: this is your higher-cost tier and includes non-preferred brand drugs and non-preferred generic drugs
13
Q
What is Tier 5?
A
Specialty tier: the specialty tier is your highest-cost tier, a specialty tier drug is very high cost or unique prescription drugs which may require special handling and/or close monitoring. Tier 5 drugs may be brand or generic
14
Q
What is step/therapy/prior authorization?
A
if drug A doesn’t work for the patient the pharmacist or your dr indicates why you cannot use drug A then we will cover drug B
15
Q
What are quantity limits?
A
for some medications (often quality-of-life medication), patients may only be authorized a certain number of pills in a designated amount of time
16
Q
What does refill too soon mean?
A
the insurance company may require that a certain amount of the medication is used before the patient can refill it
17
Q
What is an age limitation mean?
A
if a person is too old or too young, the adjudication of the prescription will be rejected (ex: Strensiq for patients over 1 years of age)
18
Q
What is a gender limitation?
A
if a person is not the expected gender, the adjudication of the prescription will be rejected (ex: PDE5 inhibitors for women)
19
Q
What is an economic case?
A
- the financial benefits outweigh the financial costs
- however, the financial benefits may not be to the same source that has to pay the costs
20
Q
What is a social case?
A
- the intervention benefits society but does not necessarily have any financial basis
21
Q
What is a business case?
A
- the source of the investment receives a financial return in a reasonable amount of time
- if the company is going to invest money, you can show them how they will get more money back
22
Q
What is CMS star rating?
A
- a five star quality rating system that rates medicare prescription drug plans
- 15 measures (Part D)
- measures can change and “passing” threshold will continue to go up
23
Q
What does the pharmacist do for CMS star ratings?
A
- check for high risk medications in the elderly
- percentage of patients who are eligible and received MTM comprehensive medication review (CMR)
- adherence: DM, HTN, Cholesterol
24
Q
Why do we care about CMS star ratings?
A
- plans care: more patients are picking their plans based on star ratings, if chronic poor rating, CMS could drop the plan.
- > specific pharmacies are not given star ratings, but how hard would it be if your plan’s numbers weren’t looking good to simply remove low performing pharmacies for their network
25
What could be next for CMS star ratings?
- % of patients who had medication reconciliation after transition of care
- % of patients who had MTM post discharge and were readmitted within 30 days
- prescriptions electronically prescribed but not obtained by the patient in 30 days
- % of resolved clinically significant drug events
- med history is being shared to EHR
26
What is failure mode an effect analysis (FMEA)?
- 5 step prospective process (nothing has happened yet)
1. map out what happens (process flow diagram)
2. identify potential points of failure (failure modes)
3. chances of error happening, consequences of error
4. will a current process catch it, is it effective?
5. take action
27
What is a root cause analysis (RCA)?
- retrospective, tries to identify the root causes of faults or problems
28
What is considered a root cause?
- a cause that once removed prevents the final undesirable event from recurring
29
What does a RCA do?
- it identifies system and process changes to reduce the risk of a similar event by focusing on systems and processes, not individuals
- provides in-depth understanding of the events being investigated by continuously asking the "5 WHYs" until root causes have been identified
- includes participation by leadership
30
Which of the following scenarios would call for a root cause analysis?
a. an administrator needs to develop a balanced budget
b. a physician is convinced that there is a better way to deliver pain medications on her unit
c. an occupational therapist quits after only 3 days on the job
d. a social worker catches a patient who is falling out of bed
C and D
31
RCA flow chart components
1. identify what happened
2. review what could have or should have happened
3. determine causes
4. develop causal statements
5. generate a list of recommended actions to prevent recurrence of the event
6. write a summary and share it with leadership, staff, and others involved in the event
32
What are the contributory factors that can influence an error in a clinical environment?
a. institutional context: external environment in which the clinic environment sits. this includes state and national regulations, financial and economic factors and the shareholders or taxpayers who support the institution
b. Organizational & management factors: ways that the values of the healthcare organization translate into clinical practice. the priorities of management send a message about the goals of the organization
c. Work environment: working conditions
d. Team factors: are all the ways that people work together
e. Individual staff: member factors describe how staff members influence safety
f. Task factors: describe aspects of clinical tasks that make them safer or less safe
g. Patient characteristics: are the unique mix of factors that the patient presents- physical condition, language, communication, social environment, etc
33
What is the National Committee for Quality Assurance (NCQA)?
- reviews an accredits managed health care organizations (voluntary)
- reports on annual performance of organizations
- develops quality standards and measures that are applicable across organizations (HEDIS- healthcare effectiveness data and information set)
34
What are HEDIS measures?
- healthcare effectiveness data and information set
- used by more than 90% of America's health plans
- can compare quality between health plans
- measures evolve every year (ex:flu shots for adults)
35
What is the Accreditation Association for Ambulatory Health Care (AAAHC)?
- leader in developing standards to advance and promote patients safety, quality care and value for ambulatory health care through peer-based accreditation processes, education and research (accredits the US Air Force & US Coast Guard)
36
What is the National Integrated Accreditation for Healthcare Organizations (NIAHO)?
- Annual inspection
| - required to conform with ISO 9001:2000 standard within 2 years after their initial survey
37
What is the Joint Commission?
- established to "continuously improve the safety and quality of health care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations"
38
What is a Sentinel Event?
- "Sentinel" because they signal the need for immediate investigation and response
- Patient Safety Event that reaches a patient and results in: death, permanent harm or severe temporary harm & intervention required to sustain life
39
What is an error?
- any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer
40
What is an adverse drug reaction (ADR)?
- medications are prescribed and administered appropriately, but something bad happens
41
What is an internal error?
- intercepted before reaching the patient (ex: caught at final check at the window)
42
What is an external error?
- reaches the patient
43
What is data?
- quantities, characters or symbols
44
What is data analysis?
- process of systematically applying statistical and/or logical techniques to describe and illustrate, condense and recap, and evaluate data
45
What is informatics?
- the science of processing data for storage and retrieval
46
What is pharmacy informatics?
- focuses on medication-related data and knowledge within the continuum of healthcare systems- including the acquisition, storage, analysis, use and dissemination- in the delivery of optimal medication-related patient care and health outcomes
47
What are some advantages of computer systems
- interaction checkers
- allergies
- dose checking
- drug specific reminders
- restricted character spaces or truncated listings
- lack of "special instructions" field
48
What is a Computerized Provider order entry (CPOE)?
- default sig lines
- default quantities
- law/policy enforcement
- short codes
- > these decrease transcription error, real-time formulary/allergy/interaction checking, therapeutic equivalent suggestions, cost information to the provider and drug specific warnings
49
What are some CPOE concerns?
- overdependence on technology
- impediment to natural workflow
- parallel systems
- warning overload
- auto fill errors
- transmission/confirmation
50
What are telephone systems?
- patient calls in their prescription to fill
| - doctor calls in prescription
51
What are electronic health records (EHR)?
- an electronic health record that includes diagnosis, pregnancy status, allergy information, and patient specific information
52
What is a Drug Utilization Review (DUR)?
- much quicker data gathering that we need to check
53
What is the Utilization Review Accreditation Commission (URAC)?
- promotes continuous improvement in the quality and efficiency of health care management through processes of accreditation and education
- > accredits: HMOs, PPOs, PBMs and other health plans
54
What is the Center for Pharmacy Practice Accreditation (CPPA)?
- recognizes pharmacy practices that provide an advanced level of patient care, services, quality, and safety
- develop and implement comprehensive programs of pharmacy practice site accreditation
- > partner with APhA, NABP and ASHP
55
What is Tricare?
- tricare is the military's health plan
56
What is managed care?
- monitor the safety and effectiveness of new drugs on the market
- alert patients to potentially dangerous drug interactions
- use medication therapy management practices to ensure patients receive the most appropriate therapies
57
What is pharmacoeconomics?
- description and analysis of the costs and consequences of pharmaceuticals and pharmaceutical services and their effects on individuals, health care systems and society
58
What is outcomes research?
- studies that attempt to identify, measure, and evaluate the end results of health care services in general
- > includes clinical, economic, and humanistic effects
59
What is applied pharmacoeconomics?
- puts pharmacoeconomic principles, methods, and theories into practice
- > quantifies the "value" of pharmacy products and pharmaceutical care services used in "real world" environments
60
What is the ECHO model?
- economic outcomes: direct costs + indirect costs + intangible costs vs consequences (effects) of different treatment alternatives
- > clinical outcomes: medical events that occur as a result of the disease or treatment
- > humanistic outcomes: consequences of the disease or treatment on patient functional status/quality of life
61
Cost-minimization analysis (CMA)
- assumes outcomes are equal between the treatment options being studied
- > measures costs only: total net costs are determined for each intervention and then compared
62
What are the advantages of using a CMA?
- least expensive option
| - simplest to do
63
What are the disadvantages of using a CMA?
- use is restricted to interventions that have the same outcomes
- evaluators must agree that the outcomes for the different interventions are equivalent in order for the study to be relevant
64
When should you use a CMA?
- within drug class formulary reviews
- same medications: different location (home health vs inpatient setting)
- comparison of different generics for the same drug entity
65
Cost-benefit analysis (CBA)
- converts inputs (costs) & outcomes (benefits) into monetary values in order to compare
- typically used to compare different programs or projects
- results are expressed as a cost-to-benefit ratio, or as the net cost or benefit
66
What are some advantages of using a CBA?
- allows comparison between interventions/programs that have different outcomes
- useful when allocating scarce funds to competing programs
67
What are some disadvantages of using a CBA?
- often difficult to translate outcomes into costs
68
Cost effectiveness analysis (CEA)?
- compares relative costs and outcomes (effects) of two or more interventions
- costs are measured in monetary values
- outcomes are measured in clinical endpoints
- typically expressed as the incremental cost-effectiveness ratio (ICER)
69
What is direct medical costs?
- resources spent on medical services or products as a direct consequence of a disease or illness
70
What is a direct non-medical cost?
- expenses related to the provision of medical care, but incurred outside the medical sector (transportation to a medical care facility, childcare, lodging)
71
What is an indirect cost?
- amounts spent or lost as an indirect consequence of illness or consumption of medical costs (lost wages due to sickness, lost production)
72
What is an intangible cost?
- pain an suffering; social and emotional stress
73
What is a dominant strategy in an ICER?
- an intervention has both lower costs and better effects
| - it will always be the cost-effective choice
74
What is a DOMINATED strategy in an ICER?
- an intervention has both higher costs and worse effects
| - it will never be the cost-effective choice
75
What are the advantages of using a CEA?
- thorough review
| - allows comparison of interventions with different levels of efficacy
76
What are the disadvantages of using a CEA?
- cannot be used to compare interventions with different health outcomes
- expensive, lengthy process
77
Cost Utility Analysis (CUA)
- similar to CEA and CBA
| - unique features: outcomes include humanistic measures (QALYs)
78
When do you use a CUA?
- health related quality of life (HRQoL) is the most important outcome
- intervention affects both morbidity and mortality and a common unit is needed
79
What are the advantages of using a CUA?
- includes patient preference in analysis of benefits (patient-centered)
- allows comparisons between different disease areas
- has common unit of measure (cost/QALYs gained) to allow comparison between interventions with different clinical endpoints
80
What are the disadvantages of using a CUA?
- utility measurements are not standardized, QALYs are difficult to measure (subjective)
- patient preferences are hard to measure
- does not take into account all societal benefits
- expensive, lengthy process
81
What is a formulary?
- commonly described as a list of medications covered by a health plan, along with details of such coverage
Pharmacoeconomics Final
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