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PA462 Final continued

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waveurflag's version from 2017-12-12 14:18

Section 1

Question Answer
The P & L statementcontains uniform categories of sales and expenses. The categories include net sales, costs of goods sold, gross margin, expenses, and net profit.
Net salestotal sales during the time period being analyzed.
Costs of goods sold (COGS)is also called the cost of sales. For retailers and wholesalers it is the total price paid for the products sold during the accounting period. It is just the price of the goods. It does NOT include selling or administrative expenses.
Gross MarginNet Sales − Cost of Goods Sold
EBITDAEarnings before interest, taxes, depreciation, and amortization
Insurance Benefits (Payer)Paid by individual, employer, government
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Section 2

Question Answer
Pharmacy benefit managers (PBM)Caremark, Express-Scripts, Aetna, Cigna, Humana, Prime Therapeutics
Gross ProfitPBM Payment – Inventory Cost
Net Profit PBM Payment – Inventory Cost – Operating Costs
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Section 3

Question Answer
P&T committee serves as an advisory group with regard to drug therapy for:medical staff hospital administration Operations, Nursing, Laboratory,… director of pharmacy
Medical Executive CommitteeOfficial clinical policy-making body Grants privileges Governs / regulates medical practice
Chair of the committeePhysician
Secretary of the CommitteeThe Director of Pharmacy
Drug Use Evaluation (DUE)Pharmacotherapeutic Quality Assurance
Failure Mode and Effects Analysis (FMEA)JC mandate for Formulary addition Multidisciplinary Predict Potential Error Points (prospective) Estimates Likely Frequency – Likely Severity Hard-wires safety practices Reassessment of frequency and severity likelyhood
PTC and Conflict of InterestMembers of the P&T committee might have a significant financial or other interest in seeing a product attain formulary status.
FormularyA continually updated list of medications and related information, representing the clinical judgment of physicians, pharmacists, and other experts in the diagnosis and/or treatment of disease and promotion of health.
Formulary System An ongoing process whereby a health care organization, through its physicians, pharmacists, and other health care professionals, establishes policies on the use of drug products and therapies, and identifies drug products and therapies that are the most medically appropriate and cost-effective to best serve the health interests of a given population.
Therapeutic Substitution: the act of dispensing a therapeutic alternate for the drug product prescribed without prior authorization of the prescriber. This is an illegal act
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Section 4

Question Answer
SWOT AnalysisStrengths, Weaknesses (internal), Opportunities, Threats (external)
SMART Objective Criteria Specific, measuruable, achievable, relevant, time bound
ROIFinancial tool that measures the economic return of a project or investment
ROI equationNet benefits / costs X 100
IRR = Internal Rate of ReturnThe discount rate often used in capital budgeting that makes the net present value of all cash flows from a particular project equal to zero. The higher a project’s IRR, the more desirable it is to undertake the project.
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Section 5

Question Answer
PPO (preferred provider organization)a network of providers to perform services to plan members. Physicians in the plan agree to charge discounted fees
HMO (health maintenance organization)Patients pay premiums and a small co-payment, usually $10. Physicians who contract with them are often paid a capitated rate.
Health Insurance ExchangeGovernment regulated A Shopping Mall for Healthcare Insurers must meet quality standards Some shoppers get supplemental financial support
The Affordable Care ActAllows Medicare to reward healthcare organizations with a share of the savings from improving care quality and reducing costs Centers for Medicaid and Medicare Services are currently testing several models of care aimed at increasing efficiency of healthcare systems. The next challenge: How long will it take to demonstrate success?
Accountable Care Organizations or ACOsGroups of healthcare professionals that deliver team-based care. Hospitals, physicians, and pharmacists work together Fee for services + Bonuses paid for quality of care and cost savings Provides incentives to each member to cooperate and communicate to drive down costs
Medication Therapy Management (MTM)Monitoring for appropriate Therapy
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Section 6

Question Answer
WHAT IS MEDICARE?A federal health insurance program that pays for medical care for the elderly and Americans with certain disabilities
Truman Proposal 1945 NHIPFirst federal government health insurance bill introduced in Congress
Drugs passed 1988 repeal 1989Medicare Advantage Act put into law
Medicare part AHospital Insurance Inpatient care in a hospital, skilled nursing facility, some home health care, and hospice care
Medicare part BMedical Insurance Outpatient doctor’s visits and medical supplies
Medicare part CCustom plans for more specific medical needs
Medicare part DPrescription drug coverage. 7 Month window for enrollment: 3 months before until 3 months after becoming 65 Alternative enrollment period: November 15th through December 31st of each year Financial penalty
Premiumthe monthly cost of enrollment for the Medicare drug plan
DeductibleAmount to pay before the plan starts to share costs of prescriptions.
Copayment / CoinsuranceAfter the deductible, these are the amounts you pay for care out of pocket Copayment is a set fee Coinsurance is a percentage
Donut Hole When total drug costs reach a certain limit, patients pay for 100% of their drug costs Patients receive additional coverage again once they’ve reached the “Catastrophic Coverage” level
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