Section 8/Week 8 Flashcards
What were the 3 options given to states for the creation of new, statewide programs expanding health insurance coverage to uninsured children?
- Expand the existing Medicaid program to include more children
- Establish a program separate & distinct from Medicaid to extend coverage to those children not eligible for Medicaid
- Use a combination of both Medicaid expansion and new program combination
What problems did states face in enrolling children in S-CHIP?
- Administratively difficult to understand
- Poor outreach
- Medicaid/S-CHIP fraud
How does the ACA work with improving the S-CHIP program?
- extends S-CHIP authorization through 2019
- provides funding through 2015
- provides tax subsidies for families that aren’t included in S-CHIP before enrollment caps
Doesn’t really address aforementioned problems
Who is least likely to accept insurance from their employer and why?
Low minimum wage job earners.
-Health insurance takes too much out of their paycheck.
What are 3 approaches for addressing the uninsured?
- Individual Mandate
- Employer Mandate
- S-CHIP
What are 2 ways to classify new pharmaceutical products
- Drugs of an entirely new class of therapeutic agent
2. Drugs that fall within an established class of therapeutic agents
What are the 2 types of FDA review for new drugs
- Priority review-
2. Standard review-
What percent of new drug applications approved by the FDA are for new compounds that represent a significant improvement in therapy
LESS THAN 10%
-Most new drugs are chemical modifications of existing drugs
Why was direct to consumer advertising banned by the AMA?
The AMA felt that only doctors had sufficient knowledge to judge claims put forth by pharmaceutical advertising
Arguments for direct to consumer adverstising
Marketing marginal benefits to consumers who are insensitive to cost. Patients may not be educated well enough to evaluate claims put forth by the advertising.
What is the Medicare Part D doughnut hole
The lack of drug coverage for seniors who have spent between $750 and $3,600 out of pocket.
Why is there a doughnut hole?
Because the budget for Medicare part D was capped at $400 million dollars over 10 years. Policy makers wanted to ensure the seniors most in need were covered with a high benefit.
They used what was left over from the $400 million budget to cover as much drug spending at 75% as they could, but this amount only totaled to $2,250 total during drug costs per year.
ERISA
Employee Retirement Income Security Act-which forbids states (other than Hawaii) from establishing new employer mandates despite the success of the Hawaii program
Individual Mandate
requires all people to purchase health insurance or pay a penalty “tax”
Employer Mandate
requiring all employers to provide health insurance to their regular employees and their families
“Me-Too” Drugs
New drugs that fall within an established class of therapeutic agents and are patentable (a new molecular entity)
Priority Review
faster review by FDA because the drug represents a “significant improvement compared to marketed products in the treatment, diagnosis or prevention of a disease.”
Tiered Formularies
Determine insurance coverage of drugs.
The uninsured are
- Mostly young adults and their children
- Mostly in families with at least one adult working on a full-time basis
- Mostly well above the poverty line
- A growing number are at or above the median family income
Hawaii Prepaid Health Care Act (1974)
- Virtually all employers were required to provide health insurance for employees working at least half time
- Cost of the insurance was to be paid by a payroll tax on employees (not to exceed 1.5% of wages), with the balance paid by the employer
Individual Mandate in Massachusetts (2006)
- Combines individual mandate on the purchase of health insurance with government subsidies to ensure affordability
- Achieved nearly universal coverage, but spending was higher than expected
In 1997, when S-CHIP was passed, there were 10 million uninsured children. How many are there today?
7.2 uninsured children.
How should we measure value in new pharmaceuticals?
Value = Benefit/Cost
Can coupons be used with Medicaid and Medicare?
Federal policy currently prohibits the use of coupons by patients in publicly subsidized drug-insurance programs such as Medicare and Medicaid.
Priority Review
constitute a “significant improvement compared to marketed products in the treatment, diagnosis or prevention of a disease”
Standard Review
drugs “appear to have therapeutic qualities similar to those of one or more already marketed drugs.”
How do managed care plans deal with the rising cost of prescription drugs?
- Formularies
2. Pharmaceutical benefit managers
What are formularies
A list of drugs the plan will pay for, each tier has different levels of co-payment
Doctors can prescribe any level, and patients have financial incentives to use lower priced drugs
What are pharmaceutical benefit managers?
Managers that administer formularies and manage pharmacy claims with retail pharmacies and patients.
They bargain with manufacturers for discounts.
What are problems with pharmaceutical benefit managers?
- They work for for-profit corporations
- Unclear who they work for
- Recent incidents involving kickbacks from manufacturers to PBMs
What is Medicaid’s response to rising pharmaceutical costs?
- Strict formularies, emphasizing “value” and older, generic drugs
- Bulk purchasing of a single drug within a category of drugs to obtain the lowest possible price
