Exam 1 - Powerpoint 3 Flashcards
Medicare Modernization Act
Passed in 2003, went into affect 2006 and introduced Part D drug benefit
Part D essential Facts
70% Medicare enrollees enrolled
15-20% Medicare beneficiaries have other drug coverage
~12% Medicare beneficiaries no drug coverage
Part D Market characteristics
Multiple buyers and sellers
Buyer decides
Part D financed….
Mostly through general revenues ~78%, 13% premiums, 9% state payments
Part D Sign up delay
If you delay, and don’t have “creditable” coverage, you pay 1% per month, for every month you delayed, forever
Formulary
List of covered drugs
Requirement for Prescription Drug Plan (PDP)
at least 2 drugs in each usP category and class
All or most of the following 6…
Antiretrovirls, antineoplastics, antidepressants, antipsychotics, anticonvulsives, immunosuppressants
Prescription Drug Plan changes
New formulary can be changed each year before open enrollment (Oct 15 - Dec 7)
After March 1 of plan year, can only make changes if give MD 60+ day notice, current patients on drug get it for rest of year
Plans cost management tools
Prior auth - doc document medical necessity
Quantity limits - cap on quantity/dose per month
Step therapy - must fail first on a preferred med
Tiers Low to High cost sharing - incentivize cheaper med
Donut hole
A coverage gap, where patient pays 100% out of pocket until they hit catastrophic phase’
2011-2019 = slowly eliminated due to ACA
2020+ it doesn’t exist
Part D premiums
Vary a lot, on network, competing plans, region, doctors, pharmacy networks
Low Income Subsidy
Zero Part D premiums low or zero cost sharing
about 30% of Part D enrollees receive it
Benchmark plans
Basic plans with sufficiently low premiums in each region, and then CMS/Medicare will pay entire premium.
If enrollee wants better plan, they pay the difference
Part D Plans vary in
Premiums
Cost-sharing
Formulary
Utilization management
Reasons for rising uninsurance
Fewer employers could afford to offer insurance to workers
Employers shifting high cost premiums onto workers
Plans and employers tried to slow rise of premiums by making insurance less generous (less cover or more cost sharing)
Workers decline coverage offered due to too expensive, not generous enough
Few people can afford own non-group plan
Premiums for employer-sponsored insurance growing much faster than wages or general inflation
High healthcare cost burden among lower income groups and the underinsured
Externalities
seeing others problems and misery makes me suffer, altruism
Job lock
workers afraid to change jobs fear of losing health insurance.
Mistmatch between workers and jobs, lower overall US productivity, weakens economy
Who pays for uncompensated care
Hospital shift $$ from paid for patients to unpaid.
Gov takes taxes to help cover unpaid care,
We end up paying for it
NeedyMeds
consolidator of websites, providing links to financial help to patients for drug access
Has prescription assistance programs (PAPs), state drug assistance, drug discount coupons
Drug discount card
Cannot be used with insurance, can only use instead of insurance
up to 80% off of cost
Industry-sponsored PAPs concerns
Copay assistance programs help patients, but they increase demand for high-cost medicines making patients insensitive to price, company charge more, insurance pay more, we pay the higher insurance costs
Mass Healthcare reform
Guaranteed issue = cant turn anyone away
Community rating = based on demographic
Merge small group markets into one risk pool
The connector = marketplace
Mass Individual mandate
all 18+ have to be covered
penalty for not insured
all college students have to have, 18-25 can stay on parents
Mass shared responsibility, Government
Medicaid program = MassHealth enrollment caps removed
CHIP = Childern’s Health Insurance Program expanded
Mass shared responsibility, Employers
mandates for moderate-large employers
Help for small businesses
ACA Triple Aim
Improve the experience of care
improve the health of populations
Reduce per capita costs of health care
