U.S Healthcare exam 2 Flashcards
Ethics in Practice
what does the Institutional Review Boards (IRBs) do
what do ethics committees do in hospitals
what do compliance officers do
what was first published in 1852
Institutional Review Boards (IRBs) –required to approve all investigational research involving human subjects to ensure their ethical treatment
Ethics Committees in hospitals can act as consultants for difficult or recurrent ethical cases
Compliance officers in corporations and managed agencies –report directly to the CEO
Code of Ethics for Pharmacists (first published 1852)
Principles of Medical Ethics
Beneficence is the duty of healthcare providers to do what
Nonmaleficence is the duty of healthcare providers to do what
Autonomy gives the patient the right to do what
Justice is the concept of treating people with what
Beneficence – obligation of healthcare providers to help people in need; duty to help others
Nonmaleficence – duty of health care providers to “do no harm”
Autonomy – right of the patients to make choices regarding their health care
Justice – concept of treating everyone in a fair manner
In the previous example, which ethical principle is being violated from the perspective of the patient?
Beneficence
Nonmaleficence
Autonomy
Justice
Autonomy
Ethical dilemmas
the provider is forced to do what
when does this often occur
Provider of medical care is forced to make a decision that violates one of the four principles of ethics
Often occur when you run out of options
Ethical Dilemma
From the earlier example, the medical resident’s desire to treat the patient with standard medical therapy demonstrates the principle of beneficence
Not giving proven effective therapy in this patient can cause serious harm – the resident wants to treat the patient and help them survive
This case is unique because the doctor is being prevented from giving care he would have given to almost any other patient in the same situation
what does the desire to not receive blood represent
For the patient, the desire to not receive blood products represents the principle of autonomy
Social-ethical dilemmas
what is connected to in reference to what
some patients are unable to receive needed care, why?
Connected to the concept of justice
Justice in reference to access to basic medical care
Some patients unable to receive needed care because they lack money and insurance or resources in their area
Distributive Justice
when does issue arise
what questions does it ask about right, care, taxes etc
all people should have what kind of access without financial barriers if healthcare was distributed based on what
what is always debated in the US about rights and privileges
Issue arises when money and resource become scarce
Allocation of the benefits and burdens in society
Is healthcare a privilege or a right? Who receives care? Who pays taxes? Who decides?
All people should have equal access to a reasonable level of care without financial barriers
If healthcare should be distributed based on need for care
In the US, the belief of healthcare as a right versus a privilege continues to be a debate
Rationing will be on exam
The limitation of resources, including money, going to medical care such that not all care expected to be beneficial is provided to all patients; and the distribution of these limited resources in a fair manner.
A conscious policy to equitably distribute limited resources
Urgent MRI scan versus an elective scan
Organ transplant waitlists
Available hospital beds
Drug shortages (or even IV bags)
Scarcity – not enough to go around
what is there a scarcity of
Scarcity of Commodity
Scarcity of Money (fiscal)
Scarcity of Resources
Scarcity of Commodity
what is one example of this matter
how is it address
what can impact the example
what is not donated enough
what question is always being asked
Organ transplantation
Addressed through macroallocation (society/large population) process, life style can affect candidacy – if you drink then you will probably not qualify because they see it as a waste
There are not enough organs donated to meet demand
135,000 patients waiting for an organ in 2015
Example of the interaction of ethics and rationing
Who should receive available organs??
United Network for Organ Sharing (UNOS)
Rationing and microallocation
what is there is constraint on
for covid 19 and ventilators what was alway questioned
Brings ethical principles into focus, sometimes tragically
Older patients with co-morbidities and poor prognosis may not receive potentially life saving therapy due to a lack of resources
Resource constraints on an institution or physician level
COVID-19 and rationing on the institution level
Not enough ventilators for all patients requiring support
Who gets mechanical ventilation?
Not enough vent technicians to monitor the ventilators being used
Who gets moved from one department to fill the gap? Is this even possible?
Rationing Healthcare
If rationing a beneficial service is necessary, medical effectiveness can help guide what
Maximizing care for healthy/screening increases resources for who
when Managing chronic diseases Medication adherence, what is usually considered
Oregon Health Plan – Rational rationing
Prioritized care for certain diagnoses and expanded coverage to 100K more patients
Plan unraveled
If rationing a beneficial service is necessary, medical effectiveness can help guide choices
Providing care when healthy vs care when sick
Maximizing care for healthy/screening increases resources for those who are sick
Managing chronic diseases
Medication adherence (beneficence vs autonomy)
Rationing and cost control
Controlling cost does not equal rationing of healthcare
Difference between reducing unnecessary interventions or eliminating administrative waste and a compromise in truly beneficial services
Summary of lecture 1 of unit 2
what can be said about ethical dilemmas
what will healthcare always struggle with
Ethics and ethical dilemmas play a role in many healthcare decisions that are made on a daily basis
Healthcare always will struggle with balancing care to individual patients with responsibly managing resources
Cost of Healthcare
Last lecture you discussed cost trends, costs vs outcomes, price x quantity, and reviewed ways to control costs
Multiple drivers of health care cost
Overuse or inappropriate utilization
Inefficient payment systems
High prices
Excessive administrative cost
Medical liability
Declining health status in the population / chronic disease
Uncontrolled costs may lead to inaccessible and inequitable care
How to Contain Costs
Decrease use of healthcare services
Decrease reimbursement for service
Decrease overhead (payer and/or provider)
Cost Control – Follow the money
payers to health plan to providers
Financing Controls: Regulatory Strategies:
passing what or creating what
medicare part ___
affordable care ___
Passing laws or creating taxes
Medicare Part A
Social insurance systems
Regulated by Federal government
Medicare payroll tax 2.9%
Affordable Care Act (ACA)
Competition Considerations…
who’s buying
does it work?
Who’s buying?
–Employer based insurance blunts the high cost of insurance
–Cost of health insurance paid by employer not seen as lost wages
–A federal tax exemption increases value for the employee and savings for the employer
Does it work?
–Premiums continue to grow at about 5% per year
–Competition has not truly been implemented in most markets
Weakness of financing controls
To be successful, they must produce decreased flow on the payment side
If payment to physicians, hospitals, and other providers increases, the budget deficits must be offset by increased taxes
Insurers may raise premiums if they cannot control what they pay to hospitals
Competition places emphasis on private health insurance to regulate payment costs
Payment: Price controls
what is set
what is an example of this
these fees set by Medicare may impact what a patient
Set reimbursement rates (ie: Canada, Medicare)
–Uniform fee schedule (fee-for-service)
- A list of fees used to pay doctors/providers for services
- These fees set by Medicare may impact the care patients receive
Payment: Price controls
Predetermined pricing for services
Competitive bidding between private insurance plans
Reference pricing
Example:
Choice Ref PPO asks each hospital in its market region to submit a bid for the cost a knee replacement. Most bids are around $40,000. High Value Hospital submits a bid for $33,000. Choice Ref informs patients enrolled in their plan that they can choose any hospital for a knee replacement, but that they will only pay the hospital $35,000 and the patient is responsible for the rest. After this policy, 75% of Choice Ref patients get knee replacements at High Value Hospital.
Problems with price control
cost shifting
patient churning
why is it hard for patients to find providers who accept medicaid
what does it result in
Cost shifting – Increasing charges to other payers to compensate for lowering the cost for one payer
Problem often avoided using uniform fee schedules or single payers
Patient churning - Inducing higher use of services (more visits/procedures/etc) to offset the lower price with higher volume in order to maintain earnings
Example: Medicaid fee-for-service pays physicians far below private insurance rates
Difficult for patients to find providers who will accept Medicaid
Results in patient churning, reduced quality of care, reduced patient satisfaction
Utilization Controls
what do payers need methods to do
what are the 3 methods to consider
Payers (ie: the health insurance) need methods to contain how often their customers (ie: the patients) use healthcare resources
Three methods to consider
Unit of payment
Patient behavior
Physician behavior
Patient Cost sharing
what is the primary intent
what does it discourage both of
what may this system reduce
who does it have little effect on
Cost sharing at point of service
– primary intent to discourage patient demand for services
- Discourages both appropriate and inappropriate care
May effectively reduce costs
US has cost sharing but the highest overall cost
Little effect on the most costly/extremely ill
Pharmacy and co-pays
Joe pays $20 each time he fills one prescription and the insurance pays for any cost above $20. Because Joe is on multiple medications for chronic disease, he pays $1200 per year on his copayments.
Utilization Management
what are people denied payment for
Thelma Graves suffers from a severe hyperthyroid condition; she and her physician agree that she will undergo thyroid surgery. Before scheduling the surgery, the physician has to call Ms. Graves’ insurance company to obtain preauthorization, without which the insurer will not pay
Fred is hospitalized for an acute MI. The hospital contacts the management firm for Mr. Brady’s insurer, which authorizes 5 hospital days. On the 4th day, Mr Brady develops a complication requiring a temporary pacemaker and additional 10 days in the hospital. After the 5th day, the physician has to call the management firm every 2 days to justify why the insurer should continue to pay
Denial of payment for unnecessary services
Supply limits
what does it depend on
what does supplier induced demand equal and thus equals what and this equals what
what are there limited resources of
where can this occur
May depend on the number of caregivers
Supplier induced demand = more surgeons equals more surgery
Limited resources (MRI scanners, hospital beds, etc.)
Can occur within a health system (HMO) or geographic region
Supply limits
Bob, in Canada, develops back pain. After several visits the family physician requests an MRI to rule out disk disease. His physician, who does not suspect disk herniation, puts him on a 5 month waiting list for an MRI.
Rob, in Canada, after lifting 40 kg at work, experience severe back pain radiating down his leg. Finding a positive straight-leg-raising test with loss of ankle reflex, his physician calls and obtains an emergency MRI scan within 3 days.
just understand the example I guess…
Summary of lecture 2
The key to cost control in the United States… “is not in the micromanagement of the doctor-patient relationship but…
the management of capacity and budgets. The American problem is to find the will to set the supply thermostat somewhere within reason.”
-Dr. John Wennberg
lecture 3 objectives
Describe the four parts of Medicare
Identify the benefits including the medications and immunizations covered under each part of Medicare
Recall the two types of plans that provide Medicare Part D coverage
Define terminology associated with Medicare Part D
Explain fraud, waste, and abuse as it relates to Medicare
Describe the four parts of Medicare
Part A: Inpatient Medical Insurance
Part B: outpatient medical insurance
Part C: a medical advantage that includes A, B, and part of D
Part D: medicare prescription drug coverage, need to add thru a private company
Recall the two types of plans that provide Medicare Part D coverage
Define terminology associated with Medicare Part D
Explain fraud, waste, and abuse as it relates to Medicare
Fraud: Intentional misrepresentation of information for financial gain
waste: overuse of services, unintentional
abuse
what is the History of Medicare
In 1965, President Lyndon B. Johnson signed the Social Security Act of 1965 establishing Medicare and Medicaid
Older and lower income individuals could not afford to purchase private health insurance
Established health insurance where the cost of health insurance was spread across tax payers in the US
What is Medicare?
A federal health insurance program that helps with the cost of healthcare in the US
Covers some medical expenses but not all; is not comprehensive
Who is enrolled in Medicare?
no need to memorize numbers but know….
64.5 million people are enrolled in Medicare(CMS, 2022)
56.6 million are 65 years or older (88%)
7.9 million are disabled (12%)
80 million people expected to be enrolled by 2030
Medicare beneficiaries as percentage of total population(19%)
New Hampshire: 23%
Massachusetts: 20%
Maine: 26% (Highest!)
(KFF,2022)
know that a lot of people are on it!
Who is eligible for Medicare?
65 years and older
Under 65 years
important to know
65 years and older - 65 years and older
Under 65 years -
- Receiving social security disability Insurance for 24 months or
- diagnosed with End-stage Renal Disease (ESRD) or Amyotrophic lateral sclerosis (ALS)
Medicare Has 4 Parts’
Each part of Medicare covers different services
Part A
Part B
Part C
Part D
Part A: Hospital Insurance
Part B: outpatient insurance
Part C: medical advantage which has A, B & some of D
Part D: medicare prescription drug coverage
Two ways to receive Medicare benefits
original medicare
medicare advantage
Original Medicare
- part A, B & D
Medicare advantage
- part C (includes part A, B, most often D)
Original Medicare
Medicare Advantage (Part C)
Original Medicare
- Includes Medicare Part A and/or Medicare Part B coverage
- Can add Medicare Part D plan for drug coverage
Medicare Advantage (Part C)
- Includes Medicare Part A and Medicare Part B and usually Part D coverage
Part A covered services
Inpatient hospital care
Skilled nursing facility (SNF) care
Home health care
Hospice care
Short-term nursing home care
Medications prescribed during an inpatient hospital or SNF stay
Part of treatment plan
Medications prescribed during hospice care
Used for symptom or pain relief
Does not cover medications for chronic conditions
Part B covered services
should know for exam
Outpatient medical care, preventative care, mental health services physical therapy
outpatient surgical services and supplies
lab tests
durable medication equipment
ambulance services
home health care
diabetic testing supplies (blood glucose monitor, test strips. lancets)
Part B covered medications
need to know
Injectable and infusible drugs given in a provider’s office
Nebulized solutions and medications used in infusion pumps
Oral cancer and anti-nausea drugs
Immunosuppressive drugs used to sustain a covered transplant
Insulin used in a pump
Part B covered immunizations
should know this
flu
hepatitis B (high or intermediate risk)
tetanus (injury related)
pneumonia
covid-19
rabies (exposure)
MedicarePart D
Prescription drug benefit
Provided by private insurance companies
Voluntary but if don’t enroll and do not maintain creditable coverage may experience a penalty in future
Plans vary by medications covered and associated costs
Open Enrollment is from October 15th through December 7th annually
Part D covered medications
Prescription brand and generic medications
- - Must be approved by the FDA and used for medically accepted indications and sold in the United States
Includes drugs, biologics, insulin and the supplies associated with the injection of insulin
Generally, must cover at least two drugs in each therapeutic category
Formularies must include all medications from six protected therapeutic categories
- - Antidepressants, antipsychotics, anticonvulsants, anticancer medications, immunosuppressants, and HIV/AIDs medications
Medications excluded by MedicarePart D
Anorexia, weight loss, or weight gain medications
Erectile dysfunction drugs when used for sexual or erectile dysfunction
Fertility drugs
Cosmetic and lifestyle drugs
Medications used for symptomatic relief of cough and cold
Prescription vitamins and minerals
Over-the-counter medications
Medications that must be administered by a health professional
Most medications used in a durable medical device
MedicarePart D covered immunizations
shingles
tetanus (prevention)
hepatitis B (low risk)
RSV- full cost >$150
Case Example
Spring is here and Lee has started working on his gardening shed. While fixing the shed, Lee stepped on a rusty nail and needed to immediately go to an outpatient clinic for a tetanus shot.
Will Medicare Part B or Part D pay forthe tetanus shot?
Answer:
Part B because it is injury related
Case Example
Emma needs to pick up supplies and medicine for the management of her diabetes. She needs blood glucose testing supplies, syringes for the injection of insulin, and a 10 ml vial of Novolog insulin.
Which part of Medicare covers the following supplies?
blood glucose testing supplies
syringes
nonovlog insulin 10 mL vial
blood glucose testing supplies_ B
syringes- D
novolog insulin 10 mL vial - D
if pumo them B
Medicare Part C
Another way to get your Medicare coverage (often called Medicare Advantage)
Must be enrolled in Part A and B to join
Coverage is provided by private companies that provide your Medicare A, B, and often D coverage
Usually offered as an HMO or PPO
Must live in plan’s service area to enroll
May provide additional benefits like gym membership, wellness classes, dental coverage, vision services
Medicare Part D Terminology
premium
deductible
initial coverage
coverage Gap/donut hole
catastrophic coverage
premium: monthly payment to belong to insurance plan
deductible: annual amount to pay before coverage begins. patient must pay for total cost of drugs up to this amount before standard copayment or coinsurance begin
initial coverage: patient pays standard plan copayment (like $10) for prescriptions on a tier or coinsurance (like 25% of the cost of the prescription) on a tier
coverage Gap/donut hole: when benefit stops after a certain spending limit is reached. patient stops paying standoff copayment sand start paying coinsurance (brand: 25%; generic: 25%)
catastrophic coverage: begins when a out of pocket spending limit is reached
phase
- deductible
- initial coverage level (after deductible and before $4,660 in total drug costs)
- coverage gap (when $4,660 in drug costs is achieved)
- catastrophic coverage (when $7,400 in out of pocket drugs costs is met)
cost of beneficiary for medications
cost of beneficiary for medications
deductible
- $505
initial coverage level
- copayment or 25% coinsurance
coverage gap
- 25%
catastrophic coverage
- $4.15%/$10.35 or 5%, whichever is higher
Medicare Part D and the Inflation Reduction Act
2023 changes
Insulin copayments will be limited to $35/month
Eliminates cost-sharing associated with vaccines covered under Medicare Part D
Pharmacists and Medicare
Pharmacists play a vital role in protecting the integrity of the Medicare program.
Misuse and fraud of Medicare dollars by providers AND patients puts financial stress on an already strained program and places health and wellness of beneficiaries at risk
Annual training required at many facilities to prevent fraud and abuse
Medicare Fraud, Waste, and Abuse
fraud
waste
abuse
fraud
- Intentional misrepresentation of data for financial gain
- Knowingly use false information to gain a payment or benefit
Waste
- Overuse
- Careless or needless use of health care benefits and resources
- Not intentional
abuse
- Receiving payment for benefits or services without misrepresenting data that results in unnecessary costs to Medicare programs
- Not intentional
Examples of FWA
(fraud waste and abuse)
Intentionally billing for administration of vaccine that you did not give =
Unintentionally billing duplicate times for one service and received payment for benefits =
Intentionally billing for a more costly service than performed =
Intentionally using someone else’s insurance coverage for services =
Unintentionally billing an inhaler that a patient does not need when he/she was admitted to the hospital =
Intentionally billing for administration of vaccine that you did not give = Fraud
Unintentionally billing duplicate times for one service and received payment for benefits=Abuse
Intentionally billing for a more costly service than performed=Fraud
Intentionally using someone else’s insurance coverage for services=Fraud
Unintentionally billing an inhaler that a patient does not need when he/she was admitted to the hospital=Waste
Penalties and Consequences
False Claims Act - Fraud
Criminal and/or civil prosecution or prison time
Suspension of provider license and/or Medicare provider status
Will not be able to get hired
Exclusion from Medicare program and/or government contracts
Financial penalties
Conclusion
medicare
medicare terms
medicare FWA
pharmacy in practice
Medicare
- The four parts of Medicare are Part A -hospital insurance; Part B – medical insurance; Part C - Medicare Advantage Plans which includes Part A, Part B, and Part D; Part D – Medicare prescription drug coverage
Medicare terminology
- Medicare Part D plans include premiums, deductibles, initial coverage payments which are usually copays but can be coinsurance, a coverage gap or donut hole in which patient pays coinsurance, and catastrophic coverage
- Medicare fraud, waste, and abuse
Pharmacists play a role in protecting the integrity of the Medicare program and annual training is required at many facilities - In pharmacy practice, you will be working with many Medicare beneficiaries!
HMO- Health Maintenance Organization
a medical insurance group that provides health services for a fixed annual fee.
A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO.
examples: group model, individual practice association (IPA), network model, and staff model.
ACO- Accountable Care Organization
groups of doctors, hospitals, and other healthcare providers, who come together voluntarily to give coordinated high-quality care to the Medicare patients they serve.
ensure that pateints are receiving the right care at the right costs
GDP- Gross Domestic Product
A comprehensive measure of U.S. economic activity. GDP measures the value of the final goods and services produced in the United States (without double counting the intermediate goods and services used up to produce them).
Health care costs
the costs of healthcare
Health care outcomes
the outcome of healthcare
Outcomes are defined as the impact of a healthcare service or intervention, and can include events or results in: Patient health status or quality of life. Patient, provider, and population attitudes and behavior. New evidence, research, prevention strategies, treatments, and care models.
Per capita
for each person; in relation to people taken individually.
Per capita is a Latin phrase literally meaning “by heads” or “for each head”, and idiomatically used to mean “per person”. The term is used in a wide variety of social sciences and statistical research contexts, including government statistics, economic indicators, and built environment studies.
Financing
provide funding for (a person or enterprise).
Payment
the exchange of money, goods, or services for goods and services in an acceptable amount to both parties and has been agreed upon in advance.
Employment-based health insurance
a health policy selected and purchased by your employer and offered to eligible employees and their dependents. These are also called group plans.
Inflation
a loss of purchasing power over time, meaning your dollar will not go as far tomorrow as it did today. It is typically expressed as the annual change in prices for everyday goods and services such as food, furniture, apparel, transportation and toys.
Cost control
the practice of identifying and reducing business expenses to increase profits, and it starts with the budgeting process.
Cost control is an important factor in maintaining and growing profitability.
Price control
government regulations on wages or prices or their rates of change.
Governments can impose such regulations on a broad range of goods and services or, more commonly, on a market for a single good.
Reference pricing
that price which users compare with the price of a competitor’s product or the previously advertised price.
Here the price of the product, which is more expensive, becomes the reference price for your product.
Price transparency - public disclosure of prices
what does it help consumers know?
what did group health plan start doing
helps consumers know the cost of a covered item or service before receiving care.
As of July 1, 2022, most group health plans and issuers of group or individual health insurance are posting pricing information for covered items and services.
Cost shifting
a situation where one group of payers overpays costs for a good or service for another group, which in total pays less than the first one.
if one payer (Medicare, say) pays less relative to costs, another (a private insurer, say) will necessarily pay more.
Fee-for-service
MassHealth pays providers directly for each covered service received by an eligible MassHealth member.
a payment model in which doctors, hospitals, and medical practices charge separately for each service they perform.
Patient churning - high volumes of brief patient visits
the percentage of patients who leave your care
Capitation
a fixed amount of money per patient per unit of time paid in advance to the physician for the delivery of health care services.
is a payment arrangement for health care service providers. It pays a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care.
Cost sharing (at point of service)
The share of costs covered by your insurance that you pay out of your own pocket
Utilization management
the practice of evaluating and monitoring the use of healthcare services to assess their appropriateness and quality.
Supply limits
maximum number of units that can ever be in circulation, and once the maximum supply is reached, no new units will be mined or issued.
Supplier-induced-demand
happens when a provider of an item or service stimulates or produces more demand for their offering than would otherwise exist in the market.
inital coverage level
After you meet your deductible, your plan will help pay for your covered prescription drugs. Your plan will pay some of the cost, and you will pay a copayment or coinsurance. How long you stay in the initial coverage period depends on your drug costs and your plan’s benefit structure. For most plans in 2023, the initial coverage period ends after you have accumulated $4,660 in total drug costs.
Note: Total drug costs include the amount you and your plan have paid for your covered drugs.
coverage gap or donut hole
This means there’s a temporary limit on what the drug plan will cover for drugs. Not everyone will enter the coverage gap. The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs.
catastrophe coverage
once your out-of-pocket spending reaches $7,400, you’ll automatically get “catastrophic coverage.” Generally, this means you’ll only pay a small coinsurance percentage (no more than 5%) or copayment for your covered Part D drugs for the rest of the calendar year.
Why should pharmacists care about costs?
The price increase associated with more than 50% of Medicare Part D drugs outpaced inflation
Abandonment rates are about 35% when the cost of medication is over $75; 45% when over $125
Medication non-adherence is associated with increased
Hospitalizations
ER visits
Mortality
Poor health outcomes
(Cubanski, DeVila, IQVIA)
Understanding Formularies
tiers
Tiering Exception
Formulary
List of medications covered by an individual prescription plan based upon current evidence-based medicine
Tier Pricing
tier 1: generic meds
tier 2: preferred brand medications
tier 3: non-preferred meds
tier 4 & 5: specialty meds
Tiering Exception
A way to lower cost-sharing by showing medications in lower tiers are ineffective or dangerous
Formulary Considerations
Prior Authorization
Quantity Limits
Step Therapy
Medication coverage restrictions seen on formularies
*Information from the prescriber to the insurance plan stating the therapeutic need for the medication is required
*Beneficiaries receive medications that are safe, effective and provide greatest value
*Restricted to a maximum dose allowed to be dispensed in a given time frame
*Beneficiaries are encouraged to use FDA-approved durations and dosages
*Information from the prescriber to the insurance plan showing the patient has failed on other medications before given approval for prescribed medication
*Beneficiaries are encouraged to use well established, cost-effective first-line medications
Case Study: JS
JS is a 55-year-old female with Harvard Pilgrim Health Care insurance offered through her employer.
She has recently been diagnosed with irregular heart rate (AFib or Atrial Fibrillation).
She is currently taking Pradaxa 150 mg BID (dabigatran etexilate mesylate) and is concerned with the price of her medication ($50 each month) as she is beginning to feel she does not even have insurance.
She asks you what can she do?
Case Study: JS
Pradaxa is Tier 4: $50/month
Alternative medication?
Tier 1 (warfarin) medication: $5/month or $15/3 months through mail order
Tier 3 (Eliquis) medication: $30/month or $90/3 months through mail order
Work with healthcare prescriber to have medication switched
benefits to add to medicare part D
extra help/low income subsidy
medicaid
State Pharmaceutical Assistance Program
Extra Help/Low Income Subsidy
Federal program available in every state
Helps with cost of Medicare Part D plan premium, deductible, copayments
Eligibility guidelines
1 person: $1,843 monthly income/$16,660 assets
2 people: $2,485 monthly income/$32,240 assets
Extra Help Benefit Categories
full extra help
partial extra help
don’t have to know too well
Monthly Income Limit
Asset Limit
Costs
$1,660 individual
$2,239 couple
$10,590 individual
$16,630 couple
Copayments: no more than $4.15/$10.35
Deductible: none
Premium: $0 options
partial extra help:
$1,843 individual
$2,485 couple
$16,660 individual
$32,2400 couple
Copayments: 15% up to threshold, then $4.15/$10.35
Deductible: $104
Premium: Reduced
Medicaid
State-sponsored health and prescription benefit programs
Referred to as dual eligible when added to Medicare
Many different coverage types depending on age and status
Eligibility guidelines vary according to income and status
Helps with copayments, premiums, and deductibles of covered
Medicare Part D medications
State Pharmaceutical Assistance Program
who administers this program?
who is it for and what does it help them with
what does it supplement and does it vary from state to state
State-administered programs that assist low-income older adults and individuals with disabilities in paying for prescriptions
Supplements Medicare Part D coverage but varies from state to state
Learn more about state programs at https://www.medicare.gov/pharmaceutical-assistance-program/state-programs.aspx
Prescription Advantage in Massachusetts
Secondary payer to Medicare Part D for most individuals
Fills in the coverage gap (“donut hole”)
Free for most people
Enroll by calling 1-800-243-4636
New Hampshire AIDS Drug Assistance Program
Diagnosis of AIDS or HIV
Income tested
Enroll by calling 603-271-4502
Case Study: EM
EM is a 65-year-old Medicare beneficiary. He contacts the Pharmacy Outreach Program. He is wondering what programs can help him with the cost of his Eliquis in the Medicare Part D donut hole. He recently applied for Medicaid and was denied.
Problem: cannot afford medication in the coverage gap
What Do We Know About EM?
Current Part D plan
Express Scripts Medicare-Saver (PDP)
Household size: 1
Monthly income: $1,500
Assets are $8,500
Pharmacy is CVS
What Can We Do To Help EM?
MassHealth
No
Already determined
Extra Help
Yes
Under the income and asset limits
EM’s monthly income: $1,500, Full Extra Help limit: $1,660/month
EM’s assets: $8,500, Full Extra Help limit: $10,590 assets
Private Assistance Options
patient assistance program
copayment foundation
special generic drug pricing program
Rx coupons
non-profit mail order pharmacy
other option s
Where To Search For Assistance Programs?
NeedyMeds is a non-profit information resource dedicated to helping people locate assistance programs to help them afford their medications and other healthcare costs
Locate programs to help with medication cost
Patient Assistance Programs
Pharmaceutical Manufacturer Programs
Provides free or low-cost brand-name medication to eligible individuals
Short-term, but can reapply each year
Usually shipped to the patient or health care provider
Helps uninsured or underinsured
Eligibility guidelines vary – typically up to 250% of FPL
Co-payment Foundations
are you automatically enrolled every year?
what are these organizations and what do they help with
what is it specific to
what must the medication be
what can be said about income
when are grants typically awarded
Charitable organizations that may help pay for certain
prescription co-payments, deductibles, and plan premiums.
Medication and Diagnosis Specific
Medication must be a covered drug w/current insurance
Income guidelines vary – some as high as 500% of the FPL
Grants are typically awarded on an annual basis
Re-application is required each year
Special Generic Pricing Programs
Low Cost Generic Medications
Offered by many retail pharmacies
Some pharmacies offer certain medications free
Available to anyone
Any income
Any age
Insured or uninsured
Not insurance
Special Generic Pricing
Low cost insulin at Wal-Mart Pharmacies
ReliOn Novolin® - $24.88/vial.
Novolin® R - Short acting
Novolin® N - Intermediate acting
Novolin® 70/30 - Insulin vials and pens
$42.88 per box (5 pens)
ReliOn Novolog ®– NEW
$72.88/vial
$85.88/box (5 pens)
Prescription Drug Coupons
Free coupons
For anyone to use
Cannot be combined with insurance
Does not discount insurance copayments
Accepted at most pharmacies
Prices available on their website
Print, or save coupon to your smartphone
Non-Profit Mail Order Pharmacy
Rx Outreach Program is a non-profit, charitable organization that provides low cost, generic medications via mail order.
Over 600 medications available
No enrollment fees
No membership fees
No shipping or handling charges
Pay only the price for the medication
Income Guidelines: $58,320 for one | $78,880 for two
Co-pay Cards
Medication specific
Offered by pharmaceutical companies for brand name medications
Reduces a co-payment, or may pay 100% of co-payment
For individuals with employer sponsored health insurance
Medicare & Medicaid beneficiaries are not eligible
Free Trial Offers
Offered by pharmaceutical companies
Typically for new medications’
Usually for anyone to use
Not readily available
Provided by physicians
Available at some pharmacies
Price Chopper Diabetes Advantedge Program
Free medication and low-cost supplies at Price Chopper grocery store pharmacy
Not insurance
Available to anyone
Strategies to reduce cost
Consider generics
Find alternative medications in drug class
Substitute an OTC product if possible
Identify a lower-cost formulation
Consider cost of retail vs. mail order pharmacy
Research Part B vs. Part D coverage
Ask the prescriber to request a tier exception
Conclusion of lecture on prescription access
Private Assistance Options
Formularies
Federal and state benefits to add to Medicare Part D
Private Assistance Options
Various options available through retail, mail order, pharmaceutical companies, and others to lower the cost of medications for individuals with Medicare, other insurance, or with no insurance
Formularies
Medications arranged by tier levels with corresponding copayments/coinsurance
Insurance companies may limit access to medications by using restrictions like prior authorizations, quantity limits, step therapy
Health care providers can impact cost by prescribing medications in lower tier levels
Federal and state benefits to add to Medicare Part D
Social Security Extra Help, Medicaid, and State Pharmaceutical Assistance Programs are programs that can help with the cost of Medicare Part D premiums, deductibles, and/or copayments
State Pharmaceutical Assistance Program
SPAPs are state-run programs that provide financial assistance to certain populations to help pay for prescriptions, though coverage varies widely by state, usage and specificity.
Formulary
an official list giving details of medicines that may be prescribed.
Prior Authorization
Approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan
quantity limits
a restriction used by Part D plans and Medicare Advantage Plans. It limits coverage of a drug to a certain amount over a certain period of time, such as 30 pills per month.
Step Therapy
If a health plan uses step therapy for certain drugs, it means that a patient can be required to try a lower cost prescription drug that treats a given condition before “stepping up” to a similar-acting, but more expensive drug.
go through class medicare plan finder and see if you are okay with it!
okay! God is good
What is the Quality of Healthcare?
Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge
How care is provided should reflect appropriate use of the most current knowledge about scientific, clinical, technical, interpersonal, manual, cognitive, and organization and management elements of health care.”
Why is Quality Important?
IOM’s “To Err Is Human: Building a Safer Health System”
44,000 deaths/yr in US from medical errors
Total national costs $17-29 billion
IOM’s “The Urgent Need to Improve Health Care Quality”
Categorized 3 quality defects
IOM’s “Crossing the Quality Chasm: A New Health System for the 21st Century”
Identified 6 quality aims
Quality of Healthcare
Despite improvements in quality, disparities still exist
Disproportionally impact minorities and low-income populations
250,000 patients die each year from preventable medical errors
1 out of 25 will develop a hospital-acquired infection
Hospitalized Medicare patients have a 1 in 4 chance of experiencing injury, harm, or death
Variation in performance (high quality versus low-quality hospitals)
Ambulatory care issues including preventative care
Quality Defects
underuse
overuse
misuse
Underuse
Evidence based practices are not used as often as they should be
ex: Ex: Neglecting mammograms for breast cancer screening
Overuse
Evidence based practices are used more frequently than the evidence supports
ex: Ex: Prescribing antibiotics for viral infections
Misuse
Processes or products are not used correctly
Ex: IM injection given IV
Quality Aims
Safe:
Effective
Efficient
Timely
Patient-centered
Equitable
Safe: keep patients safe while caring for them
Effective: develop evidence based practices to serve as standards for care
Efficient: develop evidence based practices to serve as standards for care
Timely: – avoid waits and delays for patients
Patient-centered: - care should revolve around patient, considering their preferences and giving the patient a say in their care
Equitable: get rid of disparities in healthcare – avoid unequal treatment
Components of High Quality Healthcare
A
A
C
S
O
Access; - a patient living in rural Ohio does not have access to a local dermatologist and cannot be seen for an annual skin check therefore skin cancer can not be diagnosed at an early stage.
Adequate scientific knowledge: Which drugs to use effectively and the dosing; patient started with estrogen therapy and later being diagnosed with ovarian cancer
Doing something and not knowing enough scientifically about it and so you do it wrong
Competent providers: Not having provider with adequate training and they are misdiagnosed or undiagnosed with a patient
Separation of financial and clinical decisions: Financial incentive to do a ertain procedure and doing surgery that is unnecessary—surgeon says “they do not need the surgery, but I will get more $ if I do it so I will do it”
Decrease referrals to the ER– presciber gets more $ if they not refer to the ER
Organization of healthcare institutions to maximize quality: Go to ER and inadequate staffing and do not get access to care due to low staffing—staffing is a constraint of quality because it leads to delays and not everyone is cared for
Quality Organizations
PQA
AHRQ
JCO
NCQA
IOM
USP
NQF
PQA = Pharmacy Quality Alliance
AHRQ = Agency for Healthcare Research and Quality
JCO = The Joint Commission
NCQA = National Committee for Quality Assurance
IOM = Institute of Medicine
USP = United States Pharmacopeia
NQF = National Quality Forum
just need to be able to recognize names: JCO, USP & NQF
Types of Measures- SPO
Structure
Information about staffing, capacity, and volume; MEASURMENETS RELATED TO THOSE, how many pharmacist are staffing this day, how many are staffing in reference to prescription volume, what is the workflow and is it being done correctly
Process
Procedures that are followed when providing patient care; care like patients coming in and how many are getting screened for cancer—are those processes. Being done, what is the turning rate of bedside and what is recommended clinically, or prescribing rate. Are you doing things that needs to be done for certain patients. Surgery
Outcome
Endpoints or outputs of healthcare; what are the measures, infections post surgical outcome, adverse effects, BP DM goals
Quality Improvement Shift
Newer Systems and Standards
Computerized information systems
Public reporting of quality
Pay for reporting
Pay for performance
Financially neutral clinical decision-making
Just culture concepts
practice guidelines
measuring practice patterns
Just Culture and Quality
Now we prefer to use the just culture concept
Sanctioning “bad apples” is only appropriate for reckless behavior in a just culture
Clinical Practice Guidelines
Help ensure providers have easy access to the latest evidence
Over 2,700 guidelines exist
Limitations
Must consider patient specific factors and preferences
Must use clinical judgement
Measuring Practice Patterns
Monitoring of process and outcome measures within a group or healthcare system
Useful to track measures over time and among groups
Prefer to use measure to build a better system or process rather than identify bad apples
Root cause analysis (RCA)
Why or where and error occurred
New Systems and Standards
Computerized information systems
Public reporting of quality
Pay for reporting
Pay for performance
Financially neutral clinical decision making
Value based measures
Pharmacist’s Role in Promoting Quality Healthcare
Focus on the Patient
Keep Learning
Promote Quality Culture
Focus on the Patient
- Access to Care
- Health Literacy
- Cultural Competency
Keep Learning
- Continuing Education
- Clinical Practice Guidelines
Promote Quality Culture
- Quality Measures
- Quality Improvement
- Just Culture
Pharmacists Growing Role
Development of integrated virtual care teams
Pharmacists as the most accessible healthcare professional
Potential to contribute to safe and appropriate medication use quality measures
Need to reallocate resources to improve adherence
Provide services (immunization)
Increase interaction with prescribers
Value-based networks
Move from volume to value
Platforms between pharmacies and payers evaluating data to show that value is being provided
no need to know just know that you are needed
How do we know if we have achieved high quality healthcare?
we measure!
lecture 2 objectives
Recognize the flow of dollars in the US Healthcare system
Define the different methods of controlling cost
Identify scenarios where various methods of cost control have been implemented
Analyze the limitations and potential negative impacts of cost control
Recognize the flow of dollars in the US Healthcare system
- taxpayers & employers pay a premium (or financing; includes financing controls) to the health plan
- health plan pays (includes payment controls) providers
- The most important impact is with payment!
- providers influence patient behavior and can cause patients to come back
Define the different methods of controlling cost
- Overuse or inappropriate utilization
- Inefficient payment systems
- High prices
- Excessive administrative cost
- Medical liability
- Declining health status in the population / chronic disease
Identify scenarios where various methods of cost control have been implemented
- Regulatory Strategies
- Competitive Strategies
- Price controls
- Utilization Controls
- Patient Cost Sharing
- Utilization Management
- Supply limits
Analyze the limitations and potential negative impacts of cost control
- Cost shifting – Increasing charges to other payers to compensate for lowering the cost for one payer
—Problem often avoided using uniform fee schedules or single-payers
- Patient churning - Inducing higher use of services (more visits/procedures/etc) to offset the lower price with higher volume in order to maintain earnings
———-Example: Medicaid fee-for-service pays physicians far below private insurance rates
-Difficult for patients to find providers who will accept Medicaid
-Results in patient churning, reduced quality of care, reduced patient satisfaction
Which of the following immunizations are covered under Medicare Part D? choose all that apply
A. Shingrix (Shingles vaccine)
B. Flu
C. Tetanus (prevention)
D. Pneumonia
E. Hepatitis B (low risk)
A. Shingrix (Shingles vaccine)
C. Tetanus (prevention) notice not injury related, that would be part B
E. Hepatitis B (low risk)
the patient will be automatically enrolled in the Co-payment foundation program annually.
A. True
B. False
B. False
They have to enroll themselves
Medications listed on a plan’s formulary are priced according to drug class, not tier level
A. True
B. False
B. False
they are!
hat services does Medicare Part B cover? (Select all that apply)
A. Ambulance services
B. Durable medical equipment
C. Diabetic testing supplies
D. Lab work
E. Syringes associated with the injection of insulin
A. Ambulance services
B. Durable medical equipment
C. Diabetic testing supplies
D. Lab work
all things outpatient!
Which of the following immunizations are covered under Medicare Part B? (Select all that apply)
A. Flu
B. Tetanus (prevention)
C. Pneumonia
D. Hepatitis B (High or intermediate risk)
E. Shingles
A. Flu
C. Pneumonia
D. Hepatitis B (High or intermediate risk)
What services does Medicare Part A cover? (Select all that apply)
A. Outpatient services
B. Outpatient mental healthcare
C. Hospital care
D. Skilled nursing facility care
E. Home health-care services
C. Hospital care
D. Skilled nursing facility care
E. Home health-care services
all inpatient services!
The protected therapeutic categories that must be covered under Medicare Part D include (select all that apply):
A. Diabetes
B. Immunosuppressants
C. Antihypertensive
D. Anticonvulsant
E. HIV/AIDs
B. Immunosuppressants
D. Anticonvulsant
E. HIV/AIDs
Medicare Part D insurance coverage for individual medications and immunizations is provided through
A. Federal Government
B. State Government
C. Private insurance companies
D. Board of Pharmacy
E. none of the above
C. Private insurance companies
Patient Assistance Program provided by pharmaceutical manufacturers
A. Are insurance programs that provide long-term coverage for many brand name medications
B. Assist on generic medications
C. Provide coverage for individuals who are uninsured or underinsured
D. Both A and C
E. All of the above
C. Provide coverage for individuals who are uninsured or underinsured
which of the following medications/drug classes are not covered by Medicare Part D? (Select all that apply)
A. Antipsychotics
B. Immunosuppressants
C. Weight management medications
D. Over-the-counter medications
E. Cosmetic and lifestyle drugs
C. Weight management medications
D. Over-the-counter medications
E. Cosmetic and lifestyle drugs
which part of Medicare offers gym membership
C!
where do you find Rx coupons?
goodRx.com
