Week 5 Flashcards
What else is wrong with healthcare system?
-individualism in US
-most pt poorly informed or misinformed about their healthcare and associated costs
-managed care orgs try to dec utilization of healthcare services and some meds
-HC cost inc for pt and employers = more deductibles and co-pays = inc % of income going to healthcare
-waste
-no one reminds u to take meds
-MD visits way too short
-have to get out of bed when sick
-can’t find an apple in the vending machine
-TMI to use effectively
-hardly anyone pays for prevention (sicknesss reimbursement system)
-negative info not published
individualism
-“if it’s available to me, I’m going to use”
-leads to over use
Much of public is misinformed
-lack of transparency about healthcare policy and it’s impact
-lack of knowledge among most pt when making decisions about medical care
-lack of transparency regarding cost of medical care
-great deal of misinformation on internet/social media
How managed care orgs dec utilization of healthcare services
-charge more
-dec access (in network)
-deductibles
-have to see PCP before seeing specialist
-decision makers are often not involved in patient’s care
Model for providing healthcare
-having a job w HC benefits
premium and deductible costs as % of income
-significant inc over 10 years (abt 12% of income)
-highest increase seen in the south
Waste in healtcare
-unecessary care (individualism, at least 20% deemed unecessary)
-care outside of standards and guidelines
-fraud
-provider’s time due to admin duties (prior authorizations)
-wasted science, wasted eveidence, wasted care
Best care
-collab of teams that involves pt
What roles might pharmacist play
-MTM
-tobacco cessation, immunizations, antimicrobial stewardship, substance abuse prevention and treatment, controlled substance diversion, manage drug shortages
-help pt navigate HC system
-educate abt unnecessary care/meds
-advocate for responsible health care policies
-advocate for transparency
identities of the pharmacist
-apothecary
-dispenser
-merchandiser
-expert advisor
-health care provider
Healthcare coverage 2023
-92% have insurance, but 43% underinsured, coverage gap, or uninsured
-employment-based is most common
Who is uninsured
-young
-latinx
-poor
-sick
-living in south
-below 200% of poverty level
Fed budget 2024
-medicare covered by income and payroll tax and a little bit from corporate tax
-medicare and medicaid spending are mandatory (put more money into system or dec payout?)
why do people need health insurance?
-because healthcare is expensive and uncertain
Average US life expectancy
-rising, we’re covering people for a longer amount of time
What happened prior to 1950 if u were old and poor and needed long-term care
-the poor house
-MDs came to pt house in cash
-all costs were out-of-pocket, but there was also nothing dr could really do
history of health insurance
-1920s: some hospitals offered services on a pre-paid plan
-1929: first employer-sponsored plan created by teachers in dallas
-1935: SOCIAL SECURITY ACT (no health coverage)
-WWII employer sponsored health plans as a benefit expanded as result of wage controls
-1946: Hill Burton Act = hospital construction
-1948: Prez Truman proposes national health insurance (opposed by AMA as socialist/communist)
-1954: tax break for employers in revenue Act
-entire health insurance built on employer-sponsored model
-1965: medicare and medicaid
-2010: system for self-employed who had to buy insurance on their own through echanges (ACA)
Goals of Affordable Care Act
-improve accessibility to coverage
-dec number of uninsured
-improve efficiency
-improve quality of care
-dec cost of care
30 day readmission penalties
-20% of medicare pt were readmitted within 30 days
-review of data indicates 75% of readmission are preventable
-savings to medicare could be $12 bil/year
-ACA penalizes hospitals for excessive readmissions
-over 9/10 general hospitals have be penalized at least once in the past decade
Why was ACA so controversial
-individualism
-insurance and hospital lobbies
Impact of presidential leadership on healthcare
-Teddy roosevelt: we should have healthy country but didnt really do anything
-FDR: had health probs
-Truman: first proposed national health insurance
-LBJ: medicare and medicaid
-Nixon had bros die of TB
History of medicare/Medicaid
-prioritized by LBJ 1963-1968
-passed in house and senate (JFK tried but lost by 4 votes in 1962)
-Truman and wife were first two medicare beneficiaries
-Medicare and Medicaid enacted as title 18 and title 19 of social security act July 10, 1965
Medicare history
-began July 1, 1966
-health insurance for elderly > 65yo (disabled, all ages w ESRD or ALS)
-life expectancy was 70 at the time
-19 million initially enrolled
-no dental or eye benefits
-no drug benefit for outpatients
Higher medicare enrollment
-people are living longer
Share of medicare spending
-part B is growing
Parts of Medicare
-Part A (no premium)
-Part B (premium)
-Part C (ABD)
-Part D (premium
Medicare Part A
-covers hospital costs
-no premium
-SNF care upto 100 days
-some home health/hospice care
Medicare Part B
-premium deducted from social security ($185/mo)
-cover physician costs
-med supplies
-drugs admin in MD offices
Medicare Part C
-Parts A+B+D
-Medicare Advantage
-managed care (private insurance companies that gov pays)
Medicare Part D
-drug benefit
-premium from ss ($46.50)
-2k out of pocket cap
Enrolling in Part A
-3 months before-after 65th birthday
-don’t need to be retired
-do NOT have to enroll as long as you have insurance
-starts when u start receiving ss
-most people receive Part A for free
-late enrollment impacts part B
Not covered in Part B
-long-term care
-dental
-cosmetic
-glasses
-routine foot care
-hearing aids/exams
-acupuncture
Medicare Pat B premiums
-based on income
-average is 185/mo
-
General rules for Meds w medicare
-hospital (A)
-doctor’s office (B)
-home (D)
-oral for arthritis (D)
-cancer treatment (B)
-insulin for pump (B)
-insulin for syringe (D)
Medigap (Medicare Supplement)
-not admin through CMS, but standardized by fed law
-picks up deductible for part A + deductibles and copays for part B
-89% of plans also cover part D
-options in each state
-purchased through private companies
-separate premiums and deductibles vary ($191 to $267)
-avg %217/mo in 2023 ($164/mo for most popular plan)
Medicare Part C Managed Care Plans
-Medicare Advantage
-similar to managed care plans on market (premiums, copays, deductibles, networks, optional services)
-PAs very common
-recently aggressively advertised w expanded list of services
-most managed by UnitedHealthcare
Advantage of Managed care
-improve care
-control cost
-glasses, dental, hearing, OTC meds, telehealth, fitness, transportation
-thought tho now is CMS is paying more for these plans than they would be if these pt were covered by medicare
Managed care plan disadvantages
-premiums
-prior authorizations
-gotta stay in-network
Medicare STAR rating system
-used by CMS to measure how well Medicare Advantage (Part C) and Part D plans perform
-reviewed annually
-1 to 5 stars
-staying healthy, screening, vax
-managing chronic conditions
-plan responsiveness and care
-member complaints, probs getting service, choosing to leave plan
-health plan customer services
Medicare Part D
-largest change in insurance processing in retail pharmacy history
-millions who had no Rx drug coverage now had an option
-not a single entitiy, benficiaries have to enroll and select plan (avg $46.50)
-run by private insurance companies but CMS sets minimum standards
-formularies for each plan are different
-not all medicare approved drugs will be on formulary
-pharmacists can assist pt with their selection of plan
Changes to Part D for brand-name drug costs
-max out of pocket spending is $2k which is good for brand name drugs
Medicaid
-run by state
-Hoosier Health Card run by Fam and social services admin
History of Medicaid
-Jan 1, 1966
-health insurance for poor and medically indigent of all patients
-inpatient/outpatient
-not required (AZ was last state to implement in 1982)
-fed-state partnership program
-match funds based on state per capita income - 50-83% (now up to 90% under ACA)
-federal standards for services
-managed by state gov
-wide variation in the quality and range of services in various
Medicaid by states
-califonia
-NY
-Kentucky
-almost indiana
1/5 people nationally
Medicaid milestones 2014
-ACA goes into affect expanding Medicaid eligibility for states that choose to opt in
-allows people w income level up to 138% of FPL to qualify ($17,775 or $36,570 for a fam of four)
-in 2022, >50% of the nation’s uninsured live in states that have opted out of the expanded program
-healthcare and medicaid are very political
Medicaid spending
-accounts for 1/5 of all healthcare spending
-61% of spending on long-term care is for medicaid pt
People who qualify for Medicaid
-34% are children
-23% ACA expansion adults
-20% other adults
-13% disability
-10% 65+
-diasbility and 65+ spend most (51% of spending)
Coverage of drugs in Medicaid
-complex web of money going everywhere (not really to pharmacists)
-PBM, manufacturer, beneficiaries, rebates idk
Medicaid in Indiana
-1.8 mil
-20% of population
-29% of state is low-income
-uninsured rates comparable to US rates
-1/6 adults
-3/8 children
-2/3 nursing home
1/6 medicare beneficiaries
-1/3 people w disability
-39% are POC
-65% are working
-spending: 32% to long-term care, 49% to managed care
-fed gov pays 65% and 90% of expansion
-covers 41% of births, 12-month postpartum coverage extension
States that have not adopted Medicaid expansion 2025
-Wisconsin
-Wyoming
-KS
-TX
-TN, MI, AL, GA, FL, SC
Who qualifies for Medicaid
-low-income fams that meet state requirements (<138% of FPL in IN)
-infants born to medicaid eligible women
-children < 6yo and pregnant women w incomes <158% in IN
-preg mothers are covered 12 months after pregnancy (used to be 60 days)
-certain medicare beneficiaries
Who does Medicaid serve?
-Hoosier Healthwise: children and preg
-Hoosier Care Connect: >65 not eligible for Medicare, blind, disabled
-Traditional Medicaid: > 65 eligible for Medicare, LTC, home or community-based waiver services
-Healthy Indiana Plan: low income adults 19-64 w income < 138% FPL
National enrollment and eligibility
-mandatory services: LTC, hospital, physician, home health, prenatal, family planning
-optional: pharmacy, dental, ICF, mental health rehab
-enrollment: (CHIP?) 60% of all nursing home residents, 40% of all childbirths
National eligibility
-1/3 of all children insured through medicaid
-60% of low-income children
-children are eligible for dental but few dentists participate
-ACA provides eligibility for most low income adults under 65 and fed gov pays 100% expansion cost 2014-2016, then declines to 90% in 2020
Medicaid reimbursement as a % of the medicare fee schedule
-insurance >150%
-PPOs 135-150%
-HMOs: 124%
-medicaid: from 68% to 100% as of 1/24
Rx provisions in American Rescue Plan
-require fed gov to negotiate prices! for some drugs under part b and d w highest spending starting 2026
-require drug companies to pay rebates! to medicare if prices rise faster than inflation for drugs starting 2023
-cap out-of-pocket spending! for Part D starting 2024
-limit monthly cost sharing for insulin to %35 for people with Medicare (2023)
-eliminaate cost sharing for adult vax covered under part D and improve access to vax for Medicaid pt (2023)
-expand eligibility for full benefits under Medicare Part D low-income subsidy (2024)
State of rural health
-lots of hospitals at risk for closure
-lots of hospitals stopped OBGYN access (rip preg)
-higher premature death rate
-high % of veterans living in poverty
Critical Access Hospitals (CAH)
-designated by state
-located in rural area
-no more than 35 miles from nearest hospital
-no more than 25 inpatient beds
-avg length of stay <96h
-24/7 emergency care
-allows for higher reimbursement rate
