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POP health > Week 5 > Flashcards

Week 5 Flashcards

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1
Q

What else is wrong with healthcare system?

A

-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

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2
Q

individualism

A

-“if it’s available to me, I’m going to use”
-leads to over use

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3
Q

Much of public is misinformed

A

-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

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4
Q

How managed care orgs dec utilization of healthcare services

A

-charge more
-dec access (in network)
-deductibles
-have to see PCP before seeing specialist
-decision makers are often not involved in patient’s care

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5
Q

Model for providing healthcare

A

-having a job w HC benefits

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6
Q

premium and deductible costs as % of income

A

-significant inc over 10 years (abt 12% of income)
-highest increase seen in the south

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7
Q

Waste in healtcare

A

-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

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8
Q

Best care

A

-collab of teams that involves pt

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9
Q

What roles might pharmacist play

A

-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

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10
Q

identities of the pharmacist

A

-apothecary
-dispenser
-merchandiser
-expert advisor
-health care provider

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11
Q

Healthcare coverage 2023

A

-92% have insurance, but 43% underinsured, coverage gap, or uninsured
-employment-based is most common

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12
Q

Who is uninsured

A

-young
-latinx
-poor
-sick
-living in south
-below 200% of poverty level

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13
Q

Fed budget 2024

A

-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?)

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14
Q

why do people need health insurance?

A

-because healthcare is expensive and uncertain

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15
Q

Average US life expectancy

A

-rising, we’re covering people for a longer amount of time

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16
Q

What happened prior to 1950 if u were old and poor and needed long-term care

A

-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

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17
Q

history of health insurance

A

-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)

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18
Q

Goals of Affordable Care Act

A

-improve accessibility to coverage
-dec number of uninsured
-improve efficiency
-improve quality of care
-dec cost of care

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19
Q

30 day readmission penalties

A

-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

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20
Q

Why was ACA so controversial

A

-individualism
-insurance and hospital lobbies

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21
Q

Impact of presidential leadership on healthcare

A

-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

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22
Q

History of medicare/Medicaid

A

-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

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23
Q

Medicare history

A

-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

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24
Q

Higher medicare enrollment

Study These Flashcards
A

-people are living longer

25
Share of medicare spending
-part B is growing
26
Parts of Medicare
-Part A (no premium) -Part B (premium) -Part C (ABD) -Part D (premium
27
Medicare Part A
-covers hospital costs -no premium -SNF care upto 100 days -some home health/hospice care
28
Medicare Part B
-premium deducted from social security ($185/mo) -cover physician costs -med supplies -drugs admin in MD offices
29
Medicare Part C
-Parts A+B+D -Medicare Advantage -managed care (private insurance companies that gov pays)
30
Medicare Part D
-drug benefit -premium from ss ($46.50) -2k out of pocket cap
31
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
32
Not covered in Part B
-long-term care -dental -cosmetic -glasses -routine foot care -hearing aids/exams -acupuncture
33
Medicare Pat B premiums
-based on income -average is 185/mo -
34
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)
35
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)
36
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
37
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
38
Managed care plan disadvantages
-premiums -prior authorizations -gotta stay in-network
39
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
40
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
41
Changes to Part D for brand-name drug costs
-max out of pocket spending is $2k which is good for brand name drugs
42
Medicaid
-run by state -Hoosier Health Card run by Fam and social services admin
43
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
44
Medicaid by states
-califonia -NY -Kentucky -almost indiana 1/5 people nationally
45
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
46
Medicaid spending
-accounts for 1/5 of all healthcare spending -61% of spending on long-term care is for medicaid pt
47
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)
48
Coverage of drugs in Medicaid
-complex web of money going everywhere (not really to pharmacists) -PBM, manufacturer, beneficiaries, rebates idk
49
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
50
States that have not adopted Medicaid expansion 2025
-Wisconsin -Wyoming -KS -TX -TN, MI, AL, GA, FL, SC
51
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
52
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
53
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
54
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
55
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
56
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)
57
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
58
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

POP health (17 decks)

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