516 Final Exam questions with complete solution 2023.

Define direct and indirect remuneration fees (DIR) fees and describe why they are controversial DIR fees are fees that pharmacies may see PBMs share outside of the administration fees that are generally collected after the point of sale - can be controversial because they often create a net loss for the dispensing pharmacy when the claim is processed thru Medicare part D What are the economic impacts of DIR fees on pharmacy reimbursement and overall revenue? DIR fees can create a loss in revenue that can surpass the cost of drug acquisition. This happens by essentially recalling a part of the reimbursement the pharmacy receives for drug dispensing. Understand the general trend of DIR fees over time. Fees are increasing every year - flat fees: more common in retail - fees based on a %age more common in specialty Define 'clawbacks' when a PBM charges a DIR fee after the point of sale, creating a negative reimbursement for the drug dispensed What role do star-ratings and other quality measures play in determining DIR fees? Many PBMS use the STAR ratings program as the basis for quality measures. STARS is actually a program CMS uses to rate insurance companies. Quality measures based on retail MTMs and chronic disease management (diabetes, HTN). This will create lower scores for specialty pharmacies that do NOT fill those kinds of medications (speciality pharmacies) Understand the role and impact of federal legislation and state policy in DIR fees. Federal bill has been proposed to prohibit Medicare Part D/PBMs from charging DIRs retroactively ( eliminating clawbacks ) - "Improving Transparency and Accuracy in the Medicare Part D Spending Act" Compare and contrast pharmacy benefit manager's "spread pricing" model and "pass-through" model of reimbursement. - Spread pricing model: PBM charges a payer more than it reimburses the pharmacy for a certain drug and retains the difference. Often results in lower reimbursement to pharmacies - Pass through model: PBM charge payers the same amount that they reimburse pharmacies, plus a set admin fee. What do pharmacists do in the hospita