Delivery System Flashcards
Medicare part D?
Medicaid Part D is a voluntary program providing partial prescription drug coverage. Drug plans come with a formulary (a list of covered drugs).
Problems with Medicare Part D?
- Gaps in coverage
- Administered by insurance companies
- Too many different plans that cover different medications with different costs
- No negation for lower prices
Changes the ACA has made to Medicare?
- Not a part of the insurance marketplaces
- Preventative services are covered
- Initiatives to increase coordination among providers
- Closing the donut hole by 2020 (pay until you meet your deductible, then responsible for the full cost until you meet your yearly limit) Solution for now; discounts on brand name drugs and $250 rebate, covering more drugs.
- Trump Ad. has left this alone.
Formula bankruptcy
More people are eligible for Medicare and are staying on it longer, however, too few workers are paying into the system.
What is Medicaid?
A federal and state program that provides health coverage for certain people with limited income and assets (low income, children, pregnant, disabilities). Funded by both states and federal government by taxes.
What does Medicaid cover? Who are the mandatory benefits?
BROAD LEVEL HEALTH INSURANCE:
Inpatient and outpatient hospital services, screenings, labs, x-rays, nursing facilities, non emergency transportation to medical care, physician, midwife and nurse practitioner. services.
- Expanded states now cover all low income adults 138% of the federal poverty line.
Largest covered group on Medicaid?
Children (49%)
Most expensive covered group on Medicaid?
Those with disabilities (42%)
Problems with Medicaid before the ACA?
low payments to physicians, limited coverage
Medicaid expansion?
Cover adults 138% below of the federal poverty line, simplifies CHIP enrollment process
Why did some states opt of Medicaid expansion?
National Federation of Independent Business v. Sebelius - made expansion a choice. 37 states adopted, 14 did not. States did not want handouts, could not afford expansion and have other methods to expand access.
Consequences of non medicaid expanding states?
People go uninsured, die from illnesses that could have been prevented. (people too rich for medicaid, too poor for marketplace subsides)
Intent of work requirements, what are the (+) (-)?
Conservatives argue people shouldn’t receive government aid without working for it, democrats argue it goes against the principle idea ofd Medicaid.
(+) boost the economy, if they work- it’ll make them more healthy, ideally reduce costs, only people who truly need it are funded
(-) Harmful: irregular work patterns, people may live in high pockets of unemployment, can’t get more hours due to other obligations, cost of administrative services, Add an unnecessary, undue burden
Who are the dual eligibles?
People who qualify for both medicaid and medicare. Medicare covers medical care and medicaid covers long term care services.
Does Medicaid coverage make a difference in
access to care, use, unmet needs or mortality trends?
Medicaid increases the use of health care, hard to tell if more ultization leads to better health, DECREASED MORTALITY rates.
Incentives to provide states opting out of Medicaid expansion?
OPEN ENDED
- State mandate
- People in the coverage gap receive affordable premiums, by lowering the threshold to marketplaces
- Give states more control
- Citizens pressure through ballot measures
- introduce a block grant (federal gov gives money to a state in which they can use it on whatever)
How to measure access to healthcare?
The amount of times a person is able to use healthcare services
Primary Care
BASIC IMMEDIATE PROBLEMS:
Services that cover a range of prevention, wellness, and treatment for common illnesses.
Secondary Care
SPECIALIZED CLINICAL CARE:
medical care that is provided by a specialist or facility upon referral by a primary care physician and that requires more specialized knowledge, skill, or equipment than the primary care physician can provide
Tertiary Care
MANAGEMENT OF RARE OR COMPLEX DISORDERS:
highly specialized medical care usually over an extended period of time that involves advanced and complex procedures and treatments performed by medical specialists in state-of-the-art facilities
“The donut hole” In medicare part D
A coverage gap, the point where your prescription drug expenses exceed the initial coverage limit of your plan, but have not yet reached thecatastrophic coverage level.
The Regionalized Model: The British national health service DAWSON
Like a pyramid:
Primary care level dominated by GPs (2/3 of all physicians in the UK), Secondary care based on specialists who deal with patients on an ambulatory basis but refer them back to their GPs for ongoing care–also deal with hospitalized patients, Tertiary care are specialists located at a few tertiary care medical centers
All referrals through GPs
Based on location (why is it called regionalized?)
