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|Shawn Griffin, MD, President and CEO|
|Products||Accreditation, Education and Measurement Services|
Number of employees
URAC is a Washington DC-based non-profit organizationthat helps promote health care quality through the accreditation of organizations involved in medical care services, as well as by offering education and measurement programs. Founded under the name Utilization Review Accreditation Commission in 1990, the name "was shortened to the acronym URAC in 1996 when it began accrediting other types of organizations such as health plans, pharmacies, and provider organizations".
URAC accreditation is given to an organization for a period of up to three years.An organization must go through a review again after this period expires in order to maintain their accredited status.
It is noted that "[t]he amount of time it takes for an organization to prepare an application... may vary depending on whether the appropriate work processes, policies, and procedures are in place" and "the type of accreditation you are seeking". The website states that it "usually takes four to six months to complete an accreditation review once URAC receives your completed application".
Accreditation standards for URAC programs are developed by independent experts, relying on advisory committees of experts in health care delivery. After internal discussion, the organization makes them available for public comment, refines them further based on comments, then passes them to URAC's independent advisory group for approval. URAC's board of directors gives final approval of accreditation standards. Typically these standards are updated every three years, so as to stay up to date with changes in the health care field.
As of January 2016, the URAC website listed that it offered the following accreditation programs:
Educational programs include workshops, conferences, webinars and audio conferences open to individuals and companies in the health care industry. These programs cover best practices in URAC accreditation, and news on issues in health care presented by industry professionals and URAC staff.
Pharmacists, also known as chemists or druggists, are health professionals who specialize in the use of medicines, as they deal with the composition, effects, mechanism of action and proper and effective use of drugs. Using knowledge of the mechanism of action of drugs, the pharmacist understands how they should be used to achieve maximum benefit, minimal side effects and to avoid drug interactions. Pharmacists undergo university or graduate-level education to understand the biochemical mechanisms and actions of drugs, drug uses, therapeutic roles, side effects, potential drug interactions, and monitoring parameters. This is mated to anatomy, physiology, and pathophysiology. Pharmacists interpret and communicate this specialized knowledge to patients, physicians, and other health care providers.
Health Net, LLC, a Centene company, is an American health care insurance provider. Health Net's behavioral health services subsidiary, MHN, provides behavioral health, substance abuse and employee assistance programs (EAPs) to approximately 7.3 million individuals in various states, including the company's own health plan members. The company's subsidiaries also offer managed health care products related to prescription drugs, and offer managed health care product coordination for multi-region employers and administrative services for medical groups and self-funded benefits programs. HMO, POS, insured PPO, and government contracts subsidiaries provide health benefits to approximately 5.9 million individuals in all 50 states and the District of Columbia through group, individual, Medicare, Medicaid, Tricare, and Veterans Affairs programs.
The term managed care or managed healthcare is used in the United States to describe a group of activities intended to reduce the cost of providing for-profit health care and providing American health insurance while improving the quality of that care. It has become the essentially exclusive system of delivering and receiving American health care since its implementation in the early 1980s, and has been largely unaffected by the Affordable Care Act of 2010.
...intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases. The programs may be provided in a variety of settings, such as Health Maintenance Organizations and Preferred Provider Organizations.
In health insurance in the United States, a preferred provider organization (PPO), sometimes referred to as a participating provider organization or preferred provider option, is a managed care organization of medical doctors, hospitals, and other health care providers who have agreed with an insurer or a third-party administrator to provide health care at reduced rates to the top insurer's or administrator's clients.
The Joint Commission is a United States-based nonprofit tax-exempt 501(c) organization that accredits more than 22,000 US health care organizations and programs. The international branch accredits medical services from around the world. A majority of US state governments recognize Joint Commission accreditation as a condition of licensure for the receipt of Medicaid and Medicare reimbursements.
The National Committee for Quality Assurance (NCQA) is an independent 501(c)(3) nonprofit organization in the United States that works to improve health care quality through the administration of evidence-based standards, measures, programs, and accreditation. The National Committee for Quality Assurance operates on a formula of measure, analyze, and improve and it aims to build consensus across the industry by working with policymakers, employers, doctors, and patients, as well as health plans.
A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services (CMS). The NPI has replaced the unique physician identification number (UPIN) as the required identifier for Medicare services, and is used by other payers, including commercial healthcare insurers. The transition to the NPI was mandated as part of the Administrative Simplifications portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
An independent medical review (IMR) is the process where physicians review medical cases in order to provide claims determinations for health insurance payers, workers compensation insurance payers or disability insurance payers. Peer review also is used in order to define the review of sentinel events in a hospital environment for quality management purposes such as to look at bad outcomes and determine whether there was any mis-diagnosis, mistreatment or any systemic problems involved which led to the sentinel event.
Utilization management (UM) or utilization review is the use of managed care techniques such as prior authorization that allow payers, particularly health insurance companies to manage the cost of health care benefits by assessing its appropriateness before it is provided using evidence-based criteria or guidelines.
A patient safety organization (PSO) is a group, institution, or association that improves medical care by reducing medical errors. Common functions of patient safety organizations are data collection and analysis, reporting, education, funding, and advocacy.
Thrifty White Pharmacy is an American pharmacy chain with operations in six states, Montana, North Dakota, South Dakota, Minnesota, Wisconsin, and Iowa headquartered in Plymouth, MN. It specializes in filling prescriptions, long term care consulting, community outreach, and specialty services. As of September 2016, Thrifty White received full URAC accreditation for its specialty pharmacy.
In the United States, a pharmacy benefit manager (PBM) is a third-party administrator of prescription drug programs for commercial health plans, self-insured employer plans, Medicare Part D plans, the Federal Employees Health Benefits Program, and state government employee plans. According to the American Pharmacists Association, "PBMs are primarily responsible for developing and maintaining the formulary, contracting with pharmacies, negotiating discounts and rebates with drug manufacturers, and processing and paying prescription drug claims. For the most part, they work with self-insured companies and government programs striving to maintain or reduce the pharmacy expenditures of the plan while concurrently trying to improve health care outcomes." PBMs operate inside of integrated healthcare systems, as part of retail pharmacies, and as part of insurance companies.
The Accreditation Commission for Health Care (ACHC) is a United States non-profit health care accrediting organization. It represents an alternative to the Joint Commission and CHAP, The Community Health Accreditation Program.
Health care quality is a level of value provided by any health care resource, as determined by some measurement. As with quality in other fields, it is an assessment of whether something is good enough and whether it is suitable for its purpose. The goal of health care is to provide medical resources of high quality to all who need them; that is, to ensure good quality of life, cure illnesses when possible, to extend life expectancy, and so on. Researchers use a variety of quality measures to attempt to determine health care quality, including counts of a therapy's reduction or lessening of diseases identified by medical diagnosis, a decrease in the number of risk factors which people have following preventive care, or a survey of health indicators in a population who are accessing certain kinds of care.
Specialty drugs or specialty pharmaceuticals are a recent designation of pharmaceuticals that are classified as high-cost, high complexity and/or high touch. Specialty drugs are often biologics—"drugs derived from living cells" that are injectable or infused. They are used to treat complex or rare chronic conditions such as cancer, rheumatoid arthritis, hemophilia, H.I.V. psoriasis, inflammatory bowel disease and hepatitis C. In 1990 there were 10 specialty drugs on the market, in the mid-1990s there were fewer than 30, by 2008 there were 200, and by 2015 there were 300. Drugs are often defined as specialty because their price is much higher than that of non-specialty drugs. Medicare defines any drug for which the negotiated price is $670 per month or more, as a specialty drug which is placed in a specialty tier that requires a higher patient cost sharing. Drugs are also identified as specialty when there is a special handling requirement or the drug is only available via a limited distributions network. By 2015 "specialty medications accounted for one-third of all spending on drugs in the United States, up from 19 percent in 2004 and heading toward 50 percent in the next 10 years", according to IMS Health, which tracks prescriptions. According to a 2010 article in Forbes, specialty drugs for rare diseases became more expensive "than anyone imagined" and their success came "at a time when the traditional drug business of selling medicines to the masses" was "in decline". In 2015 analysis by The Wall Street Journal suggested the large premium was due to the perceived value of rare disease treatments which usually are very expensive when compared to treatments for more common diseases.
Diplomat Pharmacy, Inc. is the largest independent provider of specialty pharmacy services in the United States. The company partners with manufacturers, payers, providers, hospitals, and more. Headquartered in Flint, Michigan, Diplomat has facilities across the United States and dispenses drugs in all 50 states. Diplomat offers specialized medication and medication management programs for patients with complex and chronic conditions such as cancer, hepatitis, multiple sclerosis, HIV and others.
Tufts Health Plan is a Massachusetts-based health insurance company under Tufts Associated Health Plans, Inc. with headquarters in Watertown, Massachusetts.
Drug utilization review refers to a review of prescribing, dispensing, administering and ingesting of medication. This authorized, structured and ongoing review is related to pharmacy benefit managers. Drug use/ utilization evaluation and medication utilization evaluations are the same as drug utilization review.