PHAR 738 Final Exam (Comprehensive) Flashcards
How much does the United States spend on healthcare? What is the insurance type breakdown? Medical expenditures breakdown?
The United States currently spends approximately 17% of its national gross domestic product (GDP) on health care (growing from 5.2% in 1960)
Private health insurance (33%), Medicare (20%), Medicaid (15%), Out of Pocket (12%), Other Third Party Payers and Programs (7%), Other government insurance (4%), Public health activity (3%)
Hospital care (31%), Physician/Clinical Services (20%), Prescription Drugs (10%), Health Insurance Administration Costs (7%), Nursing Homes and Long-Term Care (6%), Dental (4%), Medical Products (3%), Public Health Activity (3%), Home Health Care (3%), Research (2%), Other 11%)
Describe the Iron Triangle
A triple aim to optimize health system performance:
>Improving the patience experience of care (quality)
>Improving the health of populations (access)
>Reducing the per capita cost of healthcare (cost)
Outline the basic history of health insurance
> Accident insurance for railroad or steamboat travel during civil war
Accidental plans led to more expansive plans in the later 1800s
Early supplementary income plans
How was health insurance founded in America?
> Baylor Hospital Partnership in 1929 (teachers paid preset amount for number of hospital days)
American Hospital Association encourage hospitals to develop similar plans
Kaiser shipyard began supplying employee insurance during WWII
When as Medicare/Medicaid Passed?
1965
Describe the HMO act
Health Maintenance Organization Act of 1975
> requires employers with more than 25 employees and an offered health plan to include 1 HMO
Which act expanded psychiatric coverage?
Mental Health Parity Act (1996)
Describe the Health Insurance Portability and Accountability Act
1996
> Expanded was to obtain individual health insurance
created framework for federal government to collaborate with state governments to regulate insurance markets
Difference between subscriber and dependents
Subscriber purchases the policy; Dependent refers to any other members of the same policy
What is a community rating?
When all subscribers pay the same monthly premium
Describe medical underwriting
Charging different monthly premiums based on how much medical care an individual is likely to require
What forms of cost-sharing are there?
Deductible - specified amount a patient must pay in a given time period before the insurer begins to pay
Copayment - requires patients to pay a specified dollar amount each time a service is received
Coinsurance - required percentage of the cost of covered services that the patient must pay
What is the out-of-pocket max?
Out-of-Pocket Max = deductibles + copayments + coinsurances
What are some potential risk management problems?
Catastrophic Hazard – widespread, catastrophic event that would exceed a company’s ability to pay
Adverse selection – low risk individuals less likely to purchase insurance than high risk
Incentives to create losses – individuals gain from an apparent loss (i.e. physicians making more money from a fee-for-service plan)
Supplier-induced Demand – demand does not come solely from provider
Primary Agent Problem – when one person or entity is able to make decision on behalf of or that impact another person
Moral Hazard – overconsumption; when the price of a product or service decreases, the quantity demanded increases
What was concluded from the Rand Healthcare Experiment?
Participants with cost sharing model made fewer medical trips
Once patients entered the health care system, cost sharing only modestly affected the intensity or cost of an episode of care
No adverse health effects but poorest and sickest patients had better health outcomes under a free plan
Participants in cost sharing plans worries less about their health and had fewer restricted activity days
What is the breakdown of insurance coverage, by type, in the United States?
Employer Sponsored (57%)
Medicaid/Other Public (19%)
Uninsured (19%)
Private Non-group (5%)
What does the employer determine in employer sponsored insurance models?
Coverage benefits, premiums, any cost sharing components, who is eligible for coverage
What are the two types of Employer group health plans (EGHP)?
Fully-insured - the insurance company assumes risks, acts as the payer and gets any profits; this model is regulated by the state
Self-Insured - employer is the payer, assumes risks and the company gets any profits; regulated by the federal government
Besides Medicaid, list other public programs
State Children’s Health Insurance Program (S-CHIP and CHIP), Indian Health Services for Native Americans and Alaskan Natives, Veteran Health Administration, TRICARE for current members of the military as well as some retirees and their dependents
Describe COBRA
Consolidated Omnibus Budget Reconciliation Act - allows individuals to keep their EGHP for up to 18 months post-employment, making the subscriber responsible for full monthly premium
Describe Staff Model HMO
> Characterized by direct ownership of healthcare facilities and employment of physicians under a fixed salary
PROS - control over physicians actions with little risk and competition to physicians, patients also have access to everything
CONS - extremely costly for organization with less independence for physicians, physicians risk termination based on performance and patients have limited choices
Describe Group Model HMO
> Contracts with physician groups who offer services to HMO patients on a capitated basis
Same pros and cons as staff model HMO but not quite as expensive and organizations have a little less control over physicians
Kaiser Permanente is an example
Describe Network Model HMO
> Contracts with physician groups who non-exclusively offer services to HMO patients on capitated basis
Less costly with limited control over physicians
Physicians bear more risk and competition for patients is higher
Describe Independent Practice Association Model HMO
> Physicians form a separate legal organization contract with an HMO at a negotiated fee
patients have options, physicians have independence and bargaining power and the organization is typically low cost
Describe Preferred Provider Organization (PPO)
> Affiliated physicians that seek contracts with insurance plans
those in a PPO can see any provider but have an incentive to stay within network
physicians accept a discounted fee-for-service in exchange for high patient volume and quick claims payment
Describe Point of Service
> Combination of HMO and PPO
HMO characteristics - required to choose a primary care physician within a network
PPO characteristics - the provider may make referrals outside of the network, but those referrals will receive lesser compensation
The patient must fill out reimbursement paperwork if they go out of network
What are the three types of consumer driven health plans?
Health savings account (HSA)
Flexible spending accounts (FSA)
Health reimbursement accounts (HRA)
*Individuals must also enroll in a high deductible plan
Describe the key points of the Affordable Care Act
> All individuals must get health insurance or face a penalty
> Individuals will have access to health insurance (Young adults may stay on parents plan until 26, Insurers can no longer discriminate on pre-existing conditions or project health status, Policies no longer have annual policy limits)
> Employers (Small employers (under 50 employees) will receive tax credits if they offer insurance and will be allowed to purchase insurance through the exchanges, Large employers (51-200) are required to offer affordable health insurance options, Very large employers must automatically enroll employees in the company’s health insurance plan, but employees have the choice to opt out)
Who handles enrollment for Medicare?
Enrollment is handled by Social Security or by the Railroad Retirement Board (RRB)
Who handles administration of Medicare?
Centers for Medicare and Medicaid Services (CMS)
What is the deductible period for Medicare Part A?
60 days ($1260 in 2015)
What forms of Medicare should never be taken from a Social Security check?
Private insurance (Advantage or Part C) or Medigap
Who is automatically enrolled in Part A?
Those already receiving Social Security benefits or Railroad Retirement benefits
Most disabled are automatically enrolled
Describe automatic Medicare Part A enrollment for disabled?
> Enrolled after receiving 24 months of cash SS benefits
No waiting period for those with ALS or early onset Alzheimer’s
Under 65 with ESRD must apply at SSA
When is the Initial Enrollment Period for Part A
7 month period with the 4th month being the month you turn 65
*If your birthday is on the first day of a month, you may use the previous month as the enrollment period if you wish
For those with SSA disability, there is a 24 month waiting period starting on the day the first disability application was submitted (assuming it gets approved)
When are the effective dates for Part A enrollment?
Three months before birthday month - effective date is birthday month
Birthday month - month following birthday month
Month after birthday month - 2 months after birthday month
(stops increasing after +3 months)
What general services are provided for those with Part A?
Hospital inpatient services, Skilled nursing facility care, home health care (must be ordered by prescriber), hospice and blood
What hospital inpatient care services does Part A cover?
Semi-private room, meals, general nursing, other hospital services and supplies
How long are you covered in a hospital under Part A?
Days 1-60 with no copays (1260 deductible)
61-90 days: 315$ a day
91-150 days: 630$ a day
After 150 days you pay everything
What requires someone for an SNF under part A? How do you get by this?
3 consecutive midnights in hospital inpatient care.
Some advantage plans will waive this as well as the observational status/inpatient rule.
Observational status rule is a Part B benefit.
What does SNF coverage include under Part A?
Semi-private room,. meals, skilled nursing care, physical, occupational and speech therapy, medical social services, medications and medical supplies/equipment, Ambulance transport if necessary, dietary counseling
How long are covered in SNF under Part A?
First 20 days is $0
Days 21-100: $157 dollars a day
You pay everything after 100 days
What is covered under Part A for home health care?
Therapy, some health aide services, part-time skilled nursing care, 20% co-insurance for durable medical equipment from Medicare approved provider
What are the Part A conditions for home health care?
Doctor must make a plan for home health care, must be in need of specific skilled services, must be homebound and home health agency must be Medicare-approved
Coverage should continue if the patient’s condition would deteriorate if treatment was ended
What is covered under Part A for hospice care?
Two 90 day periods and unlimited 60 day periods (must have certification from physician and hospice provider must be approved by Medicare)
Unlimited respite care in Medicare certified facility for 5 days at a time.
Medical equipment supplies, drugs for pain relief and symptom control, home health aide and homemaker services, social worker services, dietary and grief counseling
How much does an individual pay for Part A hospice care?
Up to 5 dollars for prescription drugs and 5% for respite care.
What isn’t covered under Part A?
Long term care, vision and dental, hearing aids, private-duty nursing, non-prescription drugs and most nutritional supplements
What does a person pay for Part B?
104.90 premium, $147 yearly deductible and 20% co-insurance
General enrollment information for Part B
IEP - first 7 month period when first eligible for Medicare
GEP - January through March of each year with Part B going into effect July 1
Permanent 10% premium increase with each 12 months of delay
SEP - up to 8 months after active work or EGHP ends (whatever comes first)
Describe Social Security Hold Harmless Benefit
The part B premium cannot cause a decrease in SS pension relative to the previous year. If the social security increase does not cover the increased Part B premium, the increase in the Part B premium wont have to be paid
Only Part B premium NOT coming from SS pension will increase (those new to social security, Medicaid, IRMAA and those paying premium from checking accounts)
What is the late enrollment period?
Starts with 7th month of the IEP and goes to March of the current GEP
Describe IRMAA
Income Related Monthly Adjusted Amount
> Premiums are based on income with no marriage penalty
Part D and Part B IRMAAs
Based on taxes from 2 years ago
How did the Health Reform Law impact Part B?
Froze IRMAA Part B threshold until 2019, improved prevention by covering only proven preventative measures and by eliminating cost sharing for these measures in both Medicare and Medicaid, required qualified health plans to provide at a minimum coverage without cost and provided access to a comprehensive health risk assessment and creation of a personalized health plan
What are some examples of instances in which assignment must be accepted?
Medicare part-B prescription drugs, ambulance providers
What does Part B help pay for?
Doctors services, outpatient and medical and surgical services and supplies, diagnostics tests, outpatient therapy and surgery, outpatient mental health services, some preventative health care, physical, occupational and speech therapies, some home therapy and a few other medical services
What does Part B cover for preventative health care?
Welcome to Medicare extended visit, annual visits, smoking cessation clinic, some shots (flu, pneumococcal and Hep B), and specific screenings
What are the physical, occupational and speech therapy limits for Part B?
$1940 cap for Jan 1 - March 31 unless exception has been approved.
Medicare must approve maintenance of patient’s health.
What are some of the ‘other’ medical services that Part B provides?
Appropriate clinical lab test, home health services, approved durable medical equipment, blood, some diabetes supplies and ambulance services if medically necessary
What isn’t covered under Part B?
Long-term care, dental care and dentures, outpatient prescription drugs, hearing aids/exams for fitting hearing aids, routine vision and eyeglasses, routine annual physical exams and lab tests, travel outside of the US, alternative care and medical transport services
If you are on an EGHP and Medicare, who pays first?
Medicare if employer has under 20 employees (employer WILL assume you are enrolled in Medicare)
How many standard Medigap plans are there and what are they?
10: A, B, C, D, F, G, K, L, M, N
Which plans are companies required to sell?
A and F (F is the cadillac of plans)
Who regulates these Medigap plans?
The state insurance commissions (not CMS)
How does billing work with Medigap policies?
Provider bills Medicare who then notifies the Medigap plan who pays the deductible and 20% coinsurance
How do the enrollment periods for Medigap work?
IEP - first 6 months after enrollment in Part B
SEP - 63 days for A, B, D, F, K and L from date previous plan ends as long as client doesn’t lose coverage through their own fault
What are the look-back/waiting period rules with Medigap?
> Medigap plans may only obtain client’s medical history from the 2-6 months prior to effective start date of policy
> Medigap can delay paying for 3-6 months for a health problem discovered during the 2-6 month lookback
> Lookback is not permitted if the client had continuous coverage prior to enrolling in Medigap policy
Define Medicare Supplement SELECT Plans
A medigap plan that uses provider networks
Define Medicare Supplement INNOVATIVE plans
the insurance company can offer some additional benefits at no extra cost to the Medicare beneficiary
How is cost of Medigap determined?
Age, gender, smoking status and where the person lives
What is the Oregon Medigap Birthday Rule?
For a persons birthday and 30 days beyond, a Medigap policy holder can change companies without underwriting, change to an equivalent plan (can change to a plan with less coverage but not better coverage)
What is one key difference in premiums between medigap policies and advantage plans?
Advantage Plan premiums do not increase with age
What role does the CMS play in advantage plans?
They give different plans ratings on a 5 star rating scale and award higher rated plans more money
How does enrollment in advantage plans work?
> Follows the same 7 month style that standard Medicare follows
No late enrollment penalties
Can enroll or change plans without underwriting from October 15 - December 7
If late enrollment in Part B, Medicare advantage enrollment is from April 1 - Jun 30 with plan becoming effective July 1
Disenrollment lasts from Jan 1 - Feb 14
60 day special enrollment for those who lose coverage (when it’s not their fault)
Continuous special enrollment for Limited Income Subsidy (LIS) with new coverage going into effect on next day of following month
Describe the impact of the Health Reform Law on Part C
> Payments to Advantage plans restructured giving low FFS rates higher payments
plans who received a CMS rating of 4 or more stars receive a bonus
What is the once exception to the advantage plan handling billing?
Hospice - the hospice center will bill Medicare directly since this is covered under Part A
What are the different types of Advantage Plans?
HMO, HMO-POS, PPO, SNP, PFFS
Describe HMO Advantage Plans (and POS)
> Copay and coinsurance rates are set by plan but must follow Medicare rates for coinsurance
Must receive care within network with the exception of emergencies
Outside of network you may have to pay in full unless you have a POS plan (Providence)
required to select a PCP who will write referrals to any specialists
Describe a PPO Advantage Plan
> Allowed to see any doctor that accepts Medicare (including specialists without referral) (increased costs with out of network care typically)
No PCP required
Copayment and coinsurance set by plan just like HMO
Describe SNP advantage plans
> Focus on a specific type of care or economic group with benefits tailored to unique situation
prescription drug coverage is included but formularies must match up with needs of patient
Same Oct 7 - Dec 15 enrollment period
designed to serve dual eligibles, people in certain institutions or nursing homes and those with certain diseases or chronic conditions
Requires a referral from a case worker
Who sets the regulations for Part D?
CMS
Describe the enrollment period for Part D.
IEP - 7 month period when an individual first gets Medicare
Fall AEP - Oct 15-Dec 7 each year (can change plans during this time)
SEP - Jan1-Feb14 if disenrolling from an advantage plan
60 Day SEP - if plan is ended and its not your fault (continuous special enrollment for LIS)
What are the benefit components of Part D?
Yearly deductible ($0 to $360) - Patient pays full insurance price
Initial benefit period after the deductible - Insurance company pays 75% ($2212) and the patient pays 25%($737) on average
Enter the gap or donut hole - When both insurance company and patient pay $3310 combined, donut hole entered
Donut hole or coverage gap in 2016 - Brand name drugs – 5% paid by insurance, 50% discount provided by drug company with client covering 45%; Generic drugs – 42% paid by insurance company and 58% by client
Catastrophic coverage
- Once the client pays 45% of the cost of the company subsidized brand name drugs and 58% of the cost of generic drugs AND the total True Out of Pocket (TrOOP) equals $4850, the client receives catastrophic coverage [15% paid by insurance company, 80% paid by Medicare (Federal Government), Leaving 5% or $2.95 generic or $7.40, whichever is larger]
IRMAA for part D follows same breakdown as Part B IRMAA - CMS collects the IRMAA and it’s typically taken out of Social Security
What is the late enrollment penalty for Part D?
> 1% premium increase for every full month delayed beginning 3 months after turning 65 (7th month)
those with creditable coverage are the exception
Which drugs aren’t covered by Part D?
Prescribed weight-loss or gain drugs, most prescription vitamins, OTC drugs with the exception of insulin and insulin injecting supplies, fertility drugs, cosmetic, barbiturates, benzodiazepines, ED drugs
What are the 4 tiers of Part D coverage?
Tier 1 - Generic drugs
Tier 2 - “Preferred” brand name drugs
Tier 3 - “Non-preferred” brand name drugs
Tier 4 - Expensive “specialty” drugs
*the higher the tier, the higher the copay
Define Transition Fill
When a drug is discontinued by a plan, this one-time fill, or 30 day supply is required to be covered by the Medicare drug plan
Describe LIS
Stands for limited/low income subsidy
> Administered federally (SS)
Helps with Part D, generally paying the entire premium
at 135% of the FPL, client co-pays are at catastrophic coverage rates with continuous open enrollment
unlike IRMAA, there is a low income marriage penalty
Describe Medicare Savings Programs (MSP)
> State and federal money (medicaid)
client needs case worker
MSP covers Part B and D premiums leaving client with catastrophic coverage for D
income and asset caps for MSP are higher than LIS so all those in one of these programs are automatically qualified for LIS
must be a citizen or qualified immigrant, reside in a state, have an SSN and be entitled to Part A
No estate recovery in Oregon except for those in long-term care
Distinguish between the different Medicare Savings Programs
Qualified Medicare Beneficiaries (QMBs)
>Medicaid pays A and B premiums, deductibles and coinsurances
>Client pays catastrophic rates until max dollar amount reached
Specified Low-Income Medicare Beneficiaries (SLMB/SMB)
>Medicaid pays B premiums only
Qualifying Individuals (QI/SMF)
>Dependent is on fluctuating funding depending on what is available in Oregon
>Only Part B premiums covered
What are the levels of Maslow’s Hierarchy of Needs (bottom to top of pyramid)?
Physiological, safety, love/belonging, esteem, self-actualization
Describe each section of Maslow’s Hierarchy of Needs
Physiological - breathing, food, water, sex, sleep, homeostasis, excretion
Safety - security of body, of employment, of resources, of morality, of the family, of health and of property
Love/Belonging - friendship, family and sexual intimacy
Esteem - Self-esteem, confidence, achievement, respect of others, respect by others
Self-actualization - morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts
What are the individual determinants of health?
Biology (genetics), behavior (diet, nutrition, exercise, smoking status), Physical environment (macro and micro), Social environment (income and occupation)
Describe the Beveridge Model of Health Care
Health care is provided and financed by the government through tax payments
Costs per capita are lower because the government has significant control over the healthcare system
Hospitals: Most are owned by the government
Physicians: Most are government employees, but there may be private doctors who collect fees from the government
Describe the Bismark Model of Healthcare
This model is similar to employer sponsored insurance in the United States
Insurance based system usually financed jointly by employers and employees through payroll deduction
Insurance companies are required to cover everyone and cannot make a profit
Hospitals: Most are privately owned
Physicians: Most are in private practice
Describe the National Health Insurance Model
Contains elements of both the Beveridge and Bismark model
Beveridge – Government run insurance program that every citizen contributes to
>Universal programs such as this are cheaper and simpler to administer since there is only one payer
Bismark – private sector employees
Describe the Out-of-Pocket Model
Exists in approximately 40 of the world’s 200 countries and only exists in developed countries
Most nations are too poor and disorganized to provide mass medical care
Basically, the rich get medical care and the poor stay sick or die
Which countries are on the Beveridge model?
Great Britain, Japan, Switzerland
Which countries are on the Bismark model?
Germany
Which countries are on the National health Insurance Model?
Taiwan and Canada
Difference between in- and outpatient
Inpatient - patient stays in medical facility for at least one night
Outpatient - patient does not stay overnight
Describe Hospital Costs (2011 data)
39 million total hospital stays totaling 387 billion dollars.
Top 5 conditions account for 20 percent of these costs: septicemia, osteoarthritis, complication of device, newborn infants, acute MI
Describe public hospital ownership
Federal (department of defense, indian health services, VA)
State (long term care for psychiatric patients)
Local (safety net, general hospitals in underserved populations)
Prisons
Describe private hospital ownership
Not for profit (owned by secular or religious organization, historically stemmed from charity, or if profit is reinvested into hospital or community)
For profit (owned by private corporation, profit is given to shareholders and as a result are exempt from taxes by government)
Physician owned hospitals (owned by group of physicians of a specialty usually, typically for profit, number should decrease due to ACA denying Medicare reimbursement to new or expanding physician-owned hospitals)
Pros/Cons for Government owned hospitals
Provide critical, non-profit care, but are very inefficient
Pros/Cons for religious, not for profit owned hospitals
Provide the most and consistent independent funding of “charity care,” some don’t believe that religious ideologies justify tax breaks
Pros/Cons to secular not-for-profit owned hospitals
Focus on meeting the needs of the community but some argue that the benefits do not justify the tax breaks
Pros/Cons of for-profit hospitals
Hospitals have a financial incentive to be cost effective but may be too focused on profits and not enough on quality of care
Pros/Cons of physician owned hospitals
Medical staff is committed to the success of the hospital, but physicians benefit financially and are more likely to use expensive therapies
Describe non-hospital inpatient facilities
SNF: serve those who need 24 hour nursing care, duration is variable, privately administered but get funding through CMS
Long term acute care hospitals: Serve patients who need intensive, hospital-level care for weeks or months
Inpatient rehab facilities: serve patients who require comprehensive rehab, but may not be medically complex
Describe hospital-physician relationships
Most physicians function as independent contractors (may have admitting privileges, work with a medical group that contracts with the hospital aka hospitalists, or be an employee of a medical school)
Most hospitals have a mix of contracted relationships
Why is inpatient care on the decline compared with outpatient which is rising?
Technological advancement reducing recovery time and allowing more confidence in outpatient management. Increase in outpatient physicians. Hospitals are reimbursed by CMS through diagnosis related groups as opposed to length of stay.
What are the two major trend/challenges in outpatient care?
- Physician movement from solo private practices to group practices owned by a hospital or health care network.
- Physician shortages
Describe the payor and physician benefits of the movement to group practice
Payor: equal access to patients, new payments systems reward comprehensive services and the coordination of care
Physician: Guaranteed salary, steady access to patients, more comprehensive services and coordination, improved work-life balance
What are the different types of regulators in health care?
Government, insurers, private accrediting organizations and professional societies
Describe government regulators
state regulators: most common in healthcare, provide licensure and oversight of providers and facilities, control distribution of services through certificate of need and regulate some insurance coverage
Federal regulators: regulatory power derived from being the larger payer in most systems, reimbursement tied with compliance with federal standards
What is ACF
Administration for Children and Families
Division of HHS that promotes the economic and social well-being of families, children, individuals and communities through partnership, funding, guidance, training and technical assistance.
What is ACL
Administration for Community Living
Aims to maximize the independence, health and well-being of adults and those with disabilities.
What is AHRQ
Agency for Healthcare Research and Quality
Aims to provide evidence with the goal of making health care safer, higher in quality, more accessible, equitable and affordable. Also works with various organizations to make sure that the evidence is understood.
What is ATSDR
Agency for Toxic Substances and Disease Registry
Mandated by congress to provide a wide array of services concerning hazardous substances, including waste site evaluation, education and surveillance.
What is CDC
Centers for Disease Control and Prevention
Protects America from health, safety and security threats both foreign and in the US. They aim to increase the health security of the US.
What is CMS
Centers for Medicare and Medicaid Services
Responsible for regulation and administration of Medicare, Medicaid, CHIP and the Health Insurance Marketplace.
What is FDA
Food and Drug Administration
Ensure efficacy and security of human and veterinary drugs, biological products, medical devices, the food supply of the nation, cosmetics and products that emit radiation in order to protect the health of the public.
What is HRSA
Health Resources and Services Administration
This is the primary Federal agency for improving health care access.
What is IHS
Indian Health Services
Provides Federal health services to American Indians and Alaska Natives
What is SAMHSA
Substance Abuse and Mental Health Services Administration
Leads public health efforts to advance the behavioral health of the nation. Its main goals are to reduce the impact of substance abuse and mental illness on America’s communities.
What is NIH
National Institutes of Health
NIH is the national medical research agency, tasked with making important health discoveries to improve the health of population and save lives.
Describe Medicaid
Established under SS Act of 1965
Means-Tested (financial criteria or legal entitlement)
State/Federal collaborative (states administer program, Federal Matching Assistance Percentage to each state, based on per capita income and federal contributions are open-ended)
Basic 2015 Medicaid stats
66 million beneficiaries (32 children, 18 adults, 16 elderly/disabled)
Federal share ranges from 50 to 73% with 44% of all Federal funds going to states
Accounts for 16% of health care spending
Medicare and Medicaid comprise how much of federal spending? How much coverage?
About 1/4
3 in 10 Americans
Rank health insurance coverage from greatest to least
Employer, Medicaid, Medicare, Other private, uninsured, other public
FMPA Average
57%
Who is covered under Medicaid?
Less than 50 distinct Medicaid programs)
Financial Criteria
Categorical Criteria (children, pregnant women, adult in families with dependent children, persons with disabilities, elderly, or anyone under 139% of FPL)
What are the median Medicaid/CHIP eligibility thresholds?
Children = 235% Pregnant Women = 185% Working parents = 61% Jobless parents = 37% Childless Adults = 0%
Special coverage groups for Medicaid
CHIP/SCHIP (7 million children whose family income exceeds traditional Medicaid, enhanced state matching and capped allotment)
Medicare/Medicaid Dual Eligibiles (9.2 million low income Medicare eligible; helps cover monthly Medicare premiums/cost sharing as wel as long-term care)
Medicaid enrollees are _______________ and _______________________ than the privately insured
Sicker
More disabled
What mandatory items does Medicaid cover?
Physician services, Labs and x-ray, inpatient and outpatient hospital services, screening and diagnostics for those under 21, family planning, rural and federally qualified health center services, nurse midwife and nursing facility services for individuals 21 or over
What are some optional items and services that Medicaid may cover?
Prescription drugs, clinic services, dental services and dentures, physical therapy and rehab, prosthetic devices and eyeglasses, primary care case management, intermediate care facilities for mentally retarded, inpatient psychiatric care for individuals under 21, home health care, personal care services and hospice
Medicaid expenditures by service (most to least)
Payments to managed care = 21% Home Health and Personal care = 14% Inpatient = 14% Nursing Facilities = 14% Other Acute = 8% Outpatient/Clinic = 7% Physician/Lab/Xray = 4% ICF/MR = 4% Mental Health = 1%
Acute = 62% Long-Term = 33%
Medicaid enrollee percentages and expenditures
Disabled 15% (43%)
Elderly 10% (25%)
Adults 25% (13%)
Children 49% (20%)
Rx spending by source
Private insurance (43%) Medicare (28%) Out of Pocket (17%) Medicaid (8%) Dpt of Defense (2%) VA (1%) Other (1%)
1 out of 7 dollars spent on antipsychotics
Top 10 drug classes (most - least popular) for Annual Medicaid spending
Antipsychotics Antiasthmatic Antiviral Anticonvulsant Stimulant/Anti-obesity Ulcer drugs Hematologic Antidiabetic Analgesics Antidepressants
Medicaid’s Role in the Health Care System
Total health care expenditures - 15.4% Hospitilizations - 17.5% Physician services - 8.5% Nursim home/LTC - 41.3% Pharmacy - 7.8%
Describe Section 1115 Waivers
Used to give states flexibility to implement “demonstration projects”
Helps override rigidity of federal requirements.
Examples include OHP and TennCare
Describe Oregon Health Plan
Lead by Senator Kitzhaber in 1989 and used to expand enrollment.
Employer mandate to provide health insurance.
Prioritized list.
Describe OHP Prioritized List
Each legislative session would decide how much money to spend.
Oregon Health Services Commission established to create prioritized list
Services ranked and covered down list until all resources spent, but in the event of a financial shortfall, line can be moved.
Describe Medicaid Drug Pricing
States set their own reimbursement policies; payments are required to approximate drug acquisition costs plus a reasonable dispensing fee.
States use two metrics to measure acquisition costs:
AWP - specified %
Wholesale Acquisition Cost + Specified %
Describe NEW Medicaid Drug Reimbursement Methodology
AWP based methods often over estimate actual acquisition cost.
Average Actual Acquisition Cost (AAAC) through surveys of contracted pharmacies
Enhanced dispensing fees to compensate pharmacists for decreased reimbursement
Describe Medicaid Drug Pricing Rebates
Entitled to lowest or best price (Omnibus Budget Reconciliation Act 1990)
Actual drug cost to Medicaid further reduced by rebates
Federal mandatory rebate:
Non-innovator multi-source = 13% of AMP
Innovator brand name, single or multi source = 23.1 %
State supplemental rebates: sometimes tied to Preferred Drug List (PDL)
What 3 reforms did the ACA encompass to help achieve universal coverage?
Health Insurance Exchanges, Medicaid Expansion, and Employer-sponsored coverage
Describe coverage gains since implementation of ACA
7-16 million previously uninsured
12 million receive coverage through insurance marketplaces, 11 million through Medicaid expansion and 3 million young persons (under age of 26)
Reduction in number of uninsured with ACA and with ACA and all states expanding Medicaid
28%
48%
Describe the Oregon Medicaid lottery system
In 2008 Oregon used a lottery to fairly select individuals for a limited number of enrollment spots (30K selected of 90K)
Used methods similar to RCT (Increased utilization, more primary care, more likely to use preventive care, increased financial security, improved self-reported health and happiness)
Describe the Oregon Health Reform 2012-13
HB3650 created coordinated care organizations.
Community based organizations that bring together and integrate providers (physical/mental)
Global budget gave flexibility to allow innovative care approaches.
Accountability for costs, management and access
Describe financial changes in Oregon’s health
Current System (MCO/MHO/DCO/FFS): payments based on doing things with no incentives for improving health outcomes
CCO (Global budget): one lump sum; accountability for health outcomes with local vision management and shared savings; flexibility to pay for things that keep people healthy
Describe Federal Government changes with ACA
Primary changes focus on Medicare (increase in preventative care without copayments and deductibles, closing of donut hole, testing delivery programs, increasing number of beneficiaries who pay high premiums, changes to payment structure of Advantage plans, decreased payment associated with hospital-acquired infections and excessive readmissions, piloting of bundled payment)
Federal government increase in Medicaid funding
Variety of new institutes/boards that focus on health quality, coordination of care and effectiveness
By what year will brand and generics be the same for the coverage gap?
2020
Who posts advantage plan star ratings?
CMS
Describe penalty for low star rating for advantage plans?
Penalties for plans that have performed poorly for the past 3 years
Describe rebate and benchmark adjustments for 5 and 3 star plans
5 Star: Rebate 73%; benchmark = original benchmark + 5%
3 Star rating: 67% rebate; benchmark = original benchmark + 3%
Describe the CMS readmissions reduction program
CMS is reducing payments with excessive readmissions (based on 30 day readmission to any hospital for any reason; original program was just for acute MI, HF or pneumonia)
Based on the degree of excessive readmission, CMS will reduce reimbursement up to 2% for all payments
Describe state government and ACA
States can administer health insurance marketplace so that residents can opt out of federal exchange.
States can decide whether or not to accept federal money for expanding their Medicaid programs (if they accept the money they must comply with Federal ACA Medicaid changes, such as expansion up to 138% of the fpl)
Describe the Oregon Medicaid Experiment
An expansion that provided coverage to 20000 individuals via a lottery system.
Improved self-reported health, reduced financial strain, and increased diagnosis of depression
No improvements in objective measures (hypertension, diabetes, cholesterol, ER visits) and saw an increase in utilization
Effect of ACA on insurers
Placed restrictions on insurers (can’t deny coverage for pre-existing, can’t end coverage if policy holder gets sick, can’t charge high premium based on health status, waiting periods capped at 90 days, and allows dependents up to 26 on parents’ policy)
Deductible limits (2000 for individual, 4000 for family); Out-of-pocket limits (6350/12700)
No annual or lifetime benefit limits
Insurers must cover “essential health benefits” and may not require co-pays/deductibles for preventive services
Insurers must keep their medical loss ratios at 85% (large group) or 80% (small group)
Effect of ACA on small employers
Employers under 50 employees receive tax credit for offering insurance and will be allowed to get insurance through Small Business Health Options Program and apply for grants to establish employee wellness programs
Effect of ACA on large employers (51-200)
Required to offer affordable health insurance (under 8% of any full time employees income) with monetary penalties for not
Effect of ACA on very large employers
Must automatically enroll employees in the company’s health insurance plan; employees may opt out; monetary penalties for non-compliance
ACA impact on individuals
Easier to get and afford insurance (through subsidies when making 138-400% of FPL)
Marketplaces make health plan comparison easier (ratings, actuarial values, standardization, written in plain language)
Penalty for not getting insurance (95 per adult/47.50 per child or 1% of income, whichever is greater) (eventually 695 per adult, 347.50 per child or 2.5% percent of income, whichever is greater)
Groups exempt from penalty include financial hardship, religious, American Indians and those uninsured for less than 3 months
Describe the impact of ACA on uninsured individuals
30 million will still be uninsured after ACA (undocumented, financial hardship, religious or American Indians, income less than 138% of FPL but live in a state with no Medicaid expansion, or those who choose to pay penalty)
What is the Medicaid “coverage gap”
47-100% of FPL
What are the main methods of reimbursement?
Fee for service, Defined Criteria (DRG, per diagnosis; capitation, per patient; salary), pay per performance and value based purchasing
The general trend in health care reimbursement is…
The drive from volume-driven health care to value-driven health care
List the various National Measurement programs
HEDIS (Healthcare Effectiveness Data and Information Set)
CAHPS (Consumer Assessment of Healthcare Providers and Systems)
HOS (Health Outcomes Survey)
National Committee of Quality Assurance (NCQA)
Medicare Star Ratings
List National incentive programs for Medicaid
Medicare Advantage Five Star Rating Program
Oregon Coordinated Care Organization Measures
4 Sources for Medicare Advantage Plan Ratings
CMS administrative data on plan quality and member satisfaction
Consumer Assessment of Healthcare Providers and Systems (CAHPS)
Healthcare Effectiveness and Data and Information Set (HEDIS)
Health Outcomes Survey
How are medicare advantage plan scores calculated (what factors go into scoring)?
Health services (36 topics and 5 categories); Drug services (15 topics and 4 categories)
Health and drug services (48 topics total)
What are the 4 main ways to show the value of clinical pharmacy?
Quality measures, clinical outcomes, medication reconciliation, and billing
What are the five measures taken by the Pharmacy Quality Alliance (PQA)?
Medication safety:
- High risk medications in the elderly
- Appropriate treatment of BP in patients with diabetes (renin-angiotensin system antagonists, or RASA)
Medication Adherence: Measured through proportion of days covered (PDC)
- Oral anti-diabetic medications
- cholesterol medications (statins)
- Anti-hypertensive agents (RASA)
Describe ACO’s and CCO’s
ACO - accountable care organization, is a system of delivering care to patients and of receiving payments from insurers; also referred to as a medical neighborhood, which includes primary, specialty care providers and hospitals that all coordinate within an integrated infrastructure that places emphasis on primary care
Rewarded for positive outcomes and penalized for negative ones
What is Oregon doing for CCOs?
Currently tracking 17 CCO incentive metrics and 16 additional state performance metrics
Oregon is trying to determine if CCOs are effectively and adequately improving care, making quality care accessible, eliminating health disparities, and controlling costs.
How much time is a physician supposed to put in for 2500 patients?
18.7 hours a day (doesn’t include phone calls, charting, and other paperwork or administrative tasks)
What is CPCRS and why is it significant?
Clinical Pharmacy Cardiac Risk Service
Significantly reduces mortality
Transition of Care (definition, management codes)
Transition of care - the movement of a patient from one setting of care to another
Management codes:
Goal is to reduce 30 days re-hospitalization by reimbursing for care management and care coordination
Effective January 2013, uses 99495, and 99496
What is the role of the pharmacist in “transition of care?”
Decreases physician time with patient and increases the billable value of the visit (RVU) while decreasing re-hospitalization
What comes with pharmacists getting provider status?
Pharmacists services are under Medicare Part B and are reimbursable if provided in under-served areas or populations as well as professional shortage areas.
Payment models move from FFS
