PHCY 609 Exam 2 Study Set
Why is the move to value-based contracts important? - Answer US healthcare spending
rising dramatically as percentage of GDP
Opportunities for pharmacists at BCBS NC? - Answer formulary management, specialty
pharmacy, MTM, leadership, CMR, commercial clinical review, Medicare pharmacy
quality programs, provider engagement initiatives
Category 1 payment model - Answer Entirely fee-for-service; no tie to quality or value
Category 2 payment model - Answer Mostly fee-for-service (foundational payments for
infrastructure); some pay for reporting and pay for performance
Category 3 payment model - Answer APM built on fee-for-service; shared savings with
upside/downside risk; can have 3N risk-based payments not linked to quality
Category 4 payment model - Answer population based payment (can be condition or
population based, comprehensively population based, and/or with integrated
finance/delivery systems); can have capitated payments not linked to quality
Can the transition to value-based care happen quickly? Explain. - Answer No;
fee-for-service schedules must continue on a limited basis as the provider business
model changes in response to value-based paments
Role of financial risk in moving to value-based care? - Answer necessary, but not
sufficient (must transfer risk responsibly and in an appropriate way for providers)
What is Blue Premier Program? - Answer BCBS NC's shared savings model with
two-sided risk available to ACO's contracting with BCBS
What are the focuses of the Blue Premier Program? - Answer Building ACO networks,
balancing rewards based on health outcomes instead of service volume, renewing focus
on primary care, making sustainable changes to quality/affordability
Transitions of Blue Premier ACO's over time? - Answer Year 1-establish baseline,
introductions, networking
Year 2- target X improvement to baseline, continue networking
Years 3+: continue building on improvement and add downside risk
What are BCBS NC's phases of engagement - Answer phase 1: pharmacy quality &
engagement
phase 2: costs of care opportunities (value prescribing, diabetes suite)
, phase 3: advanced costs of care opportunities (site of service, preferred medical
products)
phase 4: equal collaboration between partners
What areas of focus are included in BCBS NC's diabetes suite? - Answer A1C control, Rx
adherence for diabetes & HTN/statin meds, formulary alignment with guidelines,
disease state management
What factors does BCBS NC look at for cost drivers? quality drivers? - Answer
members, medications, disease states; social drivers, diagnosis, disease state progress
What are three main initiatives the Diabetes Suite at BCBS NC is taking? - Answer value
prescribing (high cost --> metformin transitions), addressing ineffective combinations,
addressing polypharmacy
Which BCBS NC members are being targeted by the Diabetes Suite? - Answer patients
with an A1C > 8% or with over $40k in annual diabetes costs
How successful was the Diabetes Suite value prescribing initiative? - Answer Very- 70%
of eligible patients had meds changed; savings of $1.2 million for BCBS
How successful has Blue Premier been as a whole? - Answer $130 million in savings
generated, 5% reduction in unplanned hospital readmissions, & 12% increase in control
over HTN
How does access to primary care vs pharmacies differ? - Answer Patients only visit
primary care 2-4x/yr vs pharmacy 18-35x/yr; 94% of patients live w/in 5 miles of
community pharmacy but way fewer live that close to primary care
What are the 5 service models at IndyCare? - Answer urgent care, proactive health,
transitional primary care, collaborative care, & local solutions
What are some billable Medicare services related to population health? - Answer annual
wellness visit, transitional care management, chronic care management, remote patient
monitoring
What players are involved in the IndyCare "medical neighborhood"? What links
pharmacists in? - Answer PCP, community pharmacist, IndyCare providers; pharmacist
connected to IndyCare via CPA
Factors IndyCare looks at for value-based care? - Answer patient access, coordination
of care, clinical quality & Safety (abx stewardship & managing polypharmacy),
prevention & health management (smoking cessation), health IT, patient
satisfaction/loyalty
What initiatives did IndyCare use to pivot during the pandemic? - Answer virtual care,
workplace solutions, curbside health, COVID vaccines & treatment
Why is the move to value-based contracts important? - Answer US healthcare spending
rising dramatically as percentage of GDP
Opportunities for pharmacists at BCBS NC? - Answer formulary management, specialty
pharmacy, MTM, leadership, CMR, commercial clinical review, Medicare pharmacy
quality programs, provider engagement initiatives
Category 1 payment model - Answer Entirely fee-for-service; no tie to quality or value
Category 2 payment model - Answer Mostly fee-for-service (foundational payments for
infrastructure); some pay for reporting and pay for performance
Category 3 payment model - Answer APM built on fee-for-service; shared savings with
upside/downside risk; can have 3N risk-based payments not linked to quality
Category 4 payment model - Answer population based payment (can be condition or
population based, comprehensively population based, and/or with integrated
finance/delivery systems); can have capitated payments not linked to quality
Can the transition to value-based care happen quickly? Explain. - Answer No;
fee-for-service schedules must continue on a limited basis as the provider business
model changes in response to value-based paments
Role of financial risk in moving to value-based care? - Answer necessary, but not
sufficient (must transfer risk responsibly and in an appropriate way for providers)
What is Blue Premier Program? - Answer BCBS NC's shared savings model with
two-sided risk available to ACO's contracting with BCBS
What are the focuses of the Blue Premier Program? - Answer Building ACO networks,
balancing rewards based on health outcomes instead of service volume, renewing focus
on primary care, making sustainable changes to quality/affordability
Transitions of Blue Premier ACO's over time? - Answer Year 1-establish baseline,
introductions, networking
Year 2- target X improvement to baseline, continue networking
Years 3+: continue building on improvement and add downside risk
What are BCBS NC's phases of engagement - Answer phase 1: pharmacy quality &
engagement
phase 2: costs of care opportunities (value prescribing, diabetes suite)
, phase 3: advanced costs of care opportunities (site of service, preferred medical
products)
phase 4: equal collaboration between partners
What areas of focus are included in BCBS NC's diabetes suite? - Answer A1C control, Rx
adherence for diabetes & HTN/statin meds, formulary alignment with guidelines,
disease state management
What factors does BCBS NC look at for cost drivers? quality drivers? - Answer
members, medications, disease states; social drivers, diagnosis, disease state progress
What are three main initiatives the Diabetes Suite at BCBS NC is taking? - Answer value
prescribing (high cost --> metformin transitions), addressing ineffective combinations,
addressing polypharmacy
Which BCBS NC members are being targeted by the Diabetes Suite? - Answer patients
with an A1C > 8% or with over $40k in annual diabetes costs
How successful was the Diabetes Suite value prescribing initiative? - Answer Very- 70%
of eligible patients had meds changed; savings of $1.2 million for BCBS
How successful has Blue Premier been as a whole? - Answer $130 million in savings
generated, 5% reduction in unplanned hospital readmissions, & 12% increase in control
over HTN
How does access to primary care vs pharmacies differ? - Answer Patients only visit
primary care 2-4x/yr vs pharmacy 18-35x/yr; 94% of patients live w/in 5 miles of
community pharmacy but way fewer live that close to primary care
What are the 5 service models at IndyCare? - Answer urgent care, proactive health,
transitional primary care, collaborative care, & local solutions
What are some billable Medicare services related to population health? - Answer annual
wellness visit, transitional care management, chronic care management, remote patient
monitoring
What players are involved in the IndyCare "medical neighborhood"? What links
pharmacists in? - Answer PCP, community pharmacist, IndyCare providers; pharmacist
connected to IndyCare via CPA
Factors IndyCare looks at for value-based care? - Answer patient access, coordination
of care, clinical quality & Safety (abx stewardship & managing polypharmacy),
prevention & health management (smoking cessation), health IT, patient
satisfaction/loyalty
What initiatives did IndyCare use to pivot during the pandemic? - Answer virtual care,
workplace solutions, curbside health, COVID vaccines & treatment
