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!
