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152 Cards in this Set
- Front
- Back
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Define health & Disease
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Broad definitions of health and disease proposed involves complete physical, mental, and social well being, not just disease presence or absence
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Causes of death and disease in 1900
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infectious was leading cause
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leading causes of death and disease at end of 20th centur
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more chronic: heart disease, cancer, cerebrovascular dz, chronic lower respiratory disease, accidents, DM, influencza and pneumonia, Alzheimers dz, kidney dz, & septicemia
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Factors explaining health demographic change
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1. changes in standard of living or lifestyle
2. advances in public health measures (public sanitation, healthy mothers and babies prgrams? 3. progress in medical practice, including therapetic interventions in hte tretment of patients (antibiotics) ****some attribute public health advances more than innovations in medical interventions for 20th centruy improvements |
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causes of chronic illness
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some researchers believe its due to
1. sedentary lifestyle 2. poor diet, 3. smoking 4. alchol abuse |
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what happened in 1914 with public and private health insurance
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worker's comp or compulsory sickness insurance appeared at the state level
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what is in the Hill Burton act
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stated that hospitals had to accept charity patients. this act also increased hospital beds and included govt funds
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1973 and insurance
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HMO Act passed by congress: companies with >25 employees had to provide at least 1 HMO with fixed fee comprehensive medical care
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Medicaid
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established in 1965
benefits optional for states, including optional Rx coverage (Rx coverage is now included in Medicaid for all states |
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Medicare
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established in 1965.
24 mo waiting pd for disabled. state pics up Rx cost w/ Medicaid while patient (pt) is in the waiting period (pt is dual eligible) However hospital stays costs more |
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Money for Medicare
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comes from federal trust funds and from income taxes
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Money for Medicaid
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comes out of general revenue
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US and healthcare spending
Result |
US spends 2-3x more on healthcare per capita than other developed countries.
US health results are poorer |
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who is caught in the middle of health spending
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insurance companies b/c they can't just keep raising premiums
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what are some efforts to cut health care spending
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1. capitation and risk sharing
2. propective payments systems 3. cost shifting |
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capitation & risk sharing
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Managed care organization provides a fixed payment for providers. This discourages unnecassry treatments & visits & puts burden on the MD
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prospective payment systems
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hospital know up front how muc money they will get for an admittance. fixed amount of money provides incentive to fix the patient's problem the first time around.
here the burden is put on the hospital |
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cost shifting
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burden put on patient as well or somewhere else, if the patient is poor
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managed care organizations MCO used for what?
give example of MCO |
used for efficiency
ex: HMO's PPO's integrated systems |
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open market
DISADV: |
seller asks price, consumer is willing to pay.
an equilbrium is established from supply & demand disadv: expenses for healthcare are intolerable & unequally shared (sometimes the risk is high for certain individuals) |
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closed system
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govt controlled. VA system is very close to this.
healthcare is not available in the market for purchase consumers have limited choice as to when and what treatments they can have |
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traditional insurance?
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fee for service
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coverage limits
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it's a way to accommodate everyone in the market so the insurance pool will only cover to a certain amount
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group policies
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everyone must join the insurance pool, not just those that are more susceptible
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elimination period
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insurance won't cover someone until they've been a member for some time (6mo-1yr)
there could be a risk of a pre-existing illness |
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moral hazard
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changed behaviour b/c of insurance coverage
ex: use more expensive services than you normally would without insurance |
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coordination of benefits
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secondary insurance will only pay for what primary insurance does not (can't double dip with different plans
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how is spending in traditional insurance
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it's way out of control
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adverse selection
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a situation in which individual or companies purchase insurance only when they expect a loss
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which type of insurance is closer to a closed market system
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managed care
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when was managed care introduced
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in the '70s & '80s
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what was the first managed care plan
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HMO's
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define HMO's
downside |
company has fixed amount of money to manage group of ppl. money here will be managed carefully
pt is willing to give up some rights in decision making to minimize health costs |
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what was the result of introducing HMO
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between 1988-2003, as a result of rising premiums for traditional insurance, more people chose HMOs
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PPO
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preferred provider organization
somewhat between traditional and HMO low premium, choices limited among preferred providers |
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in PPO, what are the preferred providers?
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a group of companies who accept higher customer volume from a particular PPO insurance plan for a discount rate
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point of purchase organization
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POP
closer to closed system 90% of coverage in network, 60% out of network |
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treatment w/ POP
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can get treatment outside of provider circle, but must pay more
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how was HMO affected with the introduction of PPO & POP?
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became more open w/ policies when ppl were not joining b/c they couldn't find the specialist they needed.
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what is the outcome of PPO now?
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put more restrictions on their plans b/c ppl were going on their own
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deductibles
how does it help with cutting cost? |
a form of pt cost sharing that requires pts to pay their own health acre expenses until a specified dollar amount has been paid out of pocket during a given period of time, usually a year.
it discourage pts from taking advantage of claims |
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copayments
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a form of pt cost sharing that requires pts to pay a speified dollar amount every time a service is received ($50/ hosp admission or $5/RX)
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co-insurance
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percentage paid by customer after the deductible
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3 historical events that shaped the evolution of the US health care system
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1. Hill Burton act greatly increased the # of hospital beds
2. congress created financial incentives to encourage heatlh care professional education 3. congress established medicare & medicaid for the elderly, poor, and disabled. |
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HMO acronym
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health maintenance organization: coverage under health providers in the same network
includes hospital, doctor, & avoids referrals |
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JACHO
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joint commission on accrediation of healtcare organizations
a nonprofit organization that sets standards of practice for, evaluates, and accredits more than 15,000 health care organizations & programs in the US |
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DRG
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diagnosis related group
a categorization of dz of conditions created initially by the federal govt as a means to reimburse hosp prospectively for services provided to pts. there is about 500 DRG's used for the medicare payment system |
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classify hospitals by the type of service
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1. general hospitals which offer a variety of services
2. specialty hospitals which concentrate on 1 dz process (psychiatric dz or cancer) or concentrate on 1 segment of the population (children's or veterans' hosp) |
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hosp & ownership
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1. public hosp which are federal or nonfed govt (city, state)
2. nongovt: not for profit or invester owned for profit |
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what is the most of out of pocket expenses when it comes to health related categories?
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Rx drugs... americans spend 10% of health expenditure & drug costs are rising faster than other sectors.
More ppl are needing Rx drugs d/t chronic illness & aging population. |
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factors that are driving the inrease in Rx spending
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1. utilization
2. price 3. changes in the types of drugs used |
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Medicare Part D
*introduced when? *implemented when? *open enrollment pd? *AKA? *when do you enroll? * what happens if you don't enroll? *what is the exception? |
*introduced in 2003
*implemented in January 2006 *open enrollment pd is from 11/15-12/15 of every yr, then a person can choose a different PDP at that time *aka prescription drug plan (PDP) *it's an opt in plan, once they are eligible for Medicare Pt A &Pt B. *there is a penalty of 1% increase every month for failure to sign up. *the only exception is that if a person has a credible Rx plan, they can delay signing up but they have to prove it. |
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what is the payment for part D?
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a deductible has to be met ($295 in 2009) and then 25% coinsurance until $2700.
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what is the donut hole
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it's in part D. after a person pays $2700 out of pocket, from $2700-$6354, there is this donut hole in which you are responsible for 100% of the cost.
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what happens after the donut hole?
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after a person has spent $6354, then the pt is responsible for only 5%, the plan pays 15% and Medicare pays 80%
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Part D restricts what?
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restricts Medicare from negotiating for lower prices with manufacturers but individual drug plans will undoubtedly use such tactics to produce savings
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what happens to donut hole every year?
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amount of donut hole increases every year due to inflation
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what can happen with Medicare PDP plans?
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ppl may choose alternative plans for a reason, resulting in
1. adverse selection 2. induce demand 3. moral hazard |
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DOD & health insurance
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Department of defense are for those who are on active duty, retired, and their dependents. the military has its own hospitals and hires staff. there is also tricare which is a network of civilians contracted by DOD therefore DOD is self contained.
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VHA & health
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Veterans health Administration.
initially treat & provide rehab for injured servicemen, now expanded to low income & special needs veterans. |
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indian health service
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provide health care for american indians & Alaskan natives. they provide primary & specialty services often in remote areas.
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Correctional facilities
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federal, state and local
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state & local govt as health care provider
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for mentally ill & developmentally disable, county & municipal hosp, community health centers & health depts
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how does Medicare work?
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is administered at a national level & it's predominantly fee for service sys. some components of the program are outsourced, for ex, if you have a claim as a pharmacist for durable medical equipment, send the claim to FI
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how does Medicaid work?
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federal & state partnership. predominantly contracted with private sector programs that are managed care & then the govt will pay the premiums. there is some fee for service components also, about 1/3
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who is entiled to Medicare?
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you can enroll if you are at least 65yo
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if you are not 65, how can you get Medicare?
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you must be permanently disabled, you can enroll in social security administrations & have you declared permanently disable. when they start receiving SSI, they have to wait 2 yrs before they are eligibel for Medicare.
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what pts are eligible for medicare?
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end stage renal disease and ALS.
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what is part A
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AKA hosptial insurance which is a health trust fund
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Care provided patients should preserve their dignity and autonomy, how can this be done?
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1. maintain self-respect
2. feel valued as a person 3. acknowledge and encourage patient control of decision making regarding their health care. |
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Dignity is threatened by
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insensitivity of providers to the needs and feelings of patients
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moral hazard
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people overconsume healthcare.
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development of medicare program can be traced back 2 what?
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1935 social security act, although it was not enacted then, this landmark legilsation marked the beginning of the federal gobernment's central role in the area of social insurance
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what is part B Medicare
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Supplementary Medical Insurance (SMI) which provides coverage for MD's services, outpt hosp care, & a variety of other medical services not covered under part A.
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Part C
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added in 1997, was originally KA medicare+ Choice program but now is called Medicare Advantage. It expanded beneficiaries' ability to pp in a wide variety of private health plans, including HMOs & PPOs.
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which part A or B, pays a monthly premium?
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Part B which is usually deducted from their monthly benefit checks
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what happens to medicare beneficiaries who have higher income when working?
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in 2007, it was decided that they will begin paying a higher, income related Part B premium.
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how is part A financed?
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expenses here are paid from the HI trust fund, which is financed primarily thru payroll taxes paid by employees, employers, and self emplyed individuals.
additional funding is provided by beneficiary cost sharing mechanism such as premiums, deductibles, and coinsurance |
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what is a benefit period?
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it begins on the day an individual enters the hospital and ends when that person has not been ap atient in either a hospital or skilled nursing facility for 60 consecutive days.
it also ends if the person resides in a nursing home for 60 consecutive days w/o receiving skilled care. |
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how many benefit period can a person have?
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several benefit periods during a given year and there is no lifetime limit on the number of benefit pds available to individuals.
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how many days of inpatient care is covered in a benefit period?
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90 days per pd.
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what inpatient services are covered by medicare part A?
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1. semiprivate room
2. meals 3 nursing care 4 operating & recovery room 5 drugs 6 lab tests & xrays |
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how is psychiatric hospital care done under part A?
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beneficiary is entitled to just 190 days of inpt psychiatric care during his or her lifetime. psychiatric care provided in a general hosp does NOT count toward this 190 day limit.
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what are the copayments & deductibles for inpt care days?
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for days 1-60, pt is responsible for paying a deductible ($952 in 2006)
if a pt is hospitalized for more than 60 days in a pd, further cost sharing is required in the form of daily copayments. 61-90 days, $238/day for 2006) |
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Medicare & SNF
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there is no charge to the pt for the 1st 20 days of care. for days 21-100, pts are responsible for a daily copayment ($119/day in 2006)
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With Medicare, who pays for home health care services/
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part A & part B share responsibility. part A covers a max of 100 home health visits following a hosp or SNF stay of at least 3 days. after this, visits are covered by part B
part A pays the entire bill for most covered services provided by approved home health agencies w/o requiring any pt cost sharing. the only exceptiong concerns durable medical equip, for which the pt must pay a 20% coinsurance. |
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hospice care & medicare
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very little pt cost sharing is required for covered services provided under the hospice benefit. pts pay small coinsurance amts for outpt Rx drugs and inpt respite care
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medicare & traveling
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in general, medicare does not pay for health care services recived outside the US therefore elderly pts are advised to obtain other health insurance when they travel outside the country
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medicare & emergencies
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part A covers emergency services receied in all hosp, even those that do not participate in the medicare program, including hosp in Canada and Mexico.
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induced demand?
How does affect MDs? |
the increased demand for health care services that is created by the availability of insurance payment. health care providers, especially MDs, can increase utilization of health services by creating more demand for the services they provide
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Inelastic demand
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a situation in which consumers are relatively insensitive to price changes, such that an increase in price will not result in a decrease in demand.
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insurable hazard
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a type of pure risk that can lead to specific, measurable, and substantial losses that are unanticipated for an individual, but that are anticipated and relatively predictable for the group as a whole.
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per diem reimbursement
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prospective reimbursement of a flat rate per day w/o regard to actual cost.
creates incentives for hospitals to increase admissions and length of stay but decrease the intensity of services. |
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discounted fee for service reimbursement
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retrospctive reimbursement based on a negotiated fee schedule creates incentives to increase admissions, length of stay, and intensity of services
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highest cause of bankruptcy
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catastrophic medical bills
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Why is Patient center care important for Pharmacist...?
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1. Most medical treatments are for chronic conditions; patients and caregivers do more to manage therapy than any health care provider
2. Patients have questions about drug therapy that they do not ask 3. Patients make autonomous decisions about their use of medications 4. Patients often do not understand medication instructions |
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Health Belief Model:
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A health behavior theory that describes the likelihood an individual will take action to change a behavior.
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Components of the Health Belief Model theory include…
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1. susceptibility and severity of disease
2. perceived benefits and barriers 3. cues to action 4. self-efficiency 5. demographic, sociopsycological, and structural variables |
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An example of a modifying factor to the Health Belief Model is:
a. a barrier such as health care access b. a cue to action such as a health screening c. a person’s belief that s/he is very likely to get the disease d. a person’s suspicion of her own vulnerability to the disease e. a person’s perceived severity of the disease for herself |
B
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Important communication skills of healthcare professional:
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1. Empathetic listening and understanding (verbal and nonverbal)
2. Genuineness 3. Respect for the patient |
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One of the biggest barriers to effective communication
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judgement of the patient
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Steps for an effective interview
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1. opening the interview
2. asking about the drug therapy 3.Asses each medication in order to assess purpose of drugs: for example “What did your doctor tell you this medication was for?” 4. Assess ACTUAL use of medications using open-ended questions. Also want to assess difficulties in taking prescribed medicines and do not be mad at patient for not taking medicine. 5. Assess effectiveness: How well does the medicine seem to be working?” What are the goals for treatment? How is effectiveness being evaluated? 6. assess problems 7. assess allergeries 8. end the interview |
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Multidisciplinary Care
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many different professionals work for the good of the patient, although somewhat independently
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Interdisciplinary Care
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Many different professionals work for the good of the patient, COMMUNICATING EFFECTIVELY AMONG THEMSELVES AND WITH THE PATIENT
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5 professions involved in a Medical home
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a) Pharmacist
b) Physician c) Nurse d) Physical Therapist e) Social Worker |
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moral hazard?
increases what? |
A situation in which pts, with insurance coverage, over consume health care services to the extent that the additional health benefits achieved from consuming additional health services are not really worth their full costs. Nevertheless, b/c the enrollees are paying only a fraction of the costs, they still want to use the services.
Over-consumption of health services owing to moral hazard increases total health expenditures and insurance premiums |
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Medical Home is defined as
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"an approach to providing comprehensive primary care... that facilitates partnerships between individual patients, and their personal Providers, and when appropriate, the patient’s family". The provision of medical homes may allow better access to health care, increase satisfaction with care, and improve health element.
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history of health insurance
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first authorized in 1798 in marine Hospital services
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what did early health insurances do and not do?
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did not cover medical expenses but protected individuals from loss of income d/t illness. at first only covered very specific dzs.
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first hospital insurance? main problem with this?
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1929 at Baylor University hosp. main problem was that plans wee restricted to one hosptial
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Indemnity
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A form of insurance that traditionally required patients to submit claims for reimbursement. Today the term is often used to refer to any health insurance plan with fee for service reimbursement and few cost controls.
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Disadv of indemnity insurance
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presents the subscriber (us) with the burden of collecting receipts and collecting claim forms.
premiums for plans increased rapidly b/c insurance companies reimbursed on a fee for service basis and were unable to control expenditures |
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service benefit insurance
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health care providers submit claims and are paid directly by insurance companies
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adv of service benefit insurance
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allows standardization and automation of claims processing and control of costs through contractual agreements between insurance & providers
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actuarial analysis
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estimating the amount of risk for health services in return for premiums paid by the employer group
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actuary estimates 3 expenses
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1. cost for each type of service
2. utlization rate: # of services received by the group as a whole 3. administrative expenses that the fiscal intermediary incurs by the insuring & administering of the health care benefit program |
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pure risk
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a type of risk in which there is a possibility of a loss but no possibility of a gain. this type of risk is insurable
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speculative risk:
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a type of risk in which there is the possibility of either a gain or a loss. business ventures and gabling are examples of activities in which there is this risk. this type of risk is not insurable
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which type of risk is insurable?
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pure risk
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capitation
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the annual fee paid to a physician or group of physicians by each participant in a health plan
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Feature of managed care orginization (MCO)
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the use of provider networks (group of providers linked through contractual arrangemetns who will supply a full range of primary & acute health care services
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risk pool
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an arrangement in which an HMO places a portion of payments in a pool as a source for any subsequent claims that exceed projections, with the provider and the HMO sharing in the surplus (or loss) from the risk pool at the end of the year.
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the gatekeeper
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is the central component of HMO. they are primary care MDs that must coordinate and authorize all medical and lab services, specialty referral, and hospitalizations. in order to receive a coverage, a patient must have a referral.
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How hospitals and other care providers bill insurance companies
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DRG—Diagnosis-Related Group
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DRG—Diagnosis-Related Group
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A categorization of diseases of conditions created initially by the federal government as a means to reimburse hospitals prospectively for services provided to patients.
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what's not covered under Part B of medicare?
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NOT Covered: dental care; hearing aids; vision care; routine annual physical exam
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Part B assignment
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MD accepts the payment from medicare
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Rules for Part D
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a) Formulary
i) Some drugs not covered b) Financial Incentives i) copays and deductibles c) Prior Authorization i) meet certain criteria before prescribing d) Step Care i) Oldest cheapest before newest more expensive e) Quantity limits i) How much of a drug you can receive at one time. |
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Prerequisites of Insurance
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a) Known peril with predictable frequency
b) Peril occurs at random among individuals c) Losses are accidental d) Losses are substantial e) Losses are determinate f) Policy holder has an insurable interest |
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catastrophic hazard
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a situation in which an insurance company incurs excessive losses d/t widespread & catastrophic events such as hurricanes, acts of war, and earthquakes. compnies that provide casualty insurance limit their exposure for catastrophic events by trying to avoid insuring large numbers of policyholders in the same geographic area.
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how to solve catastrophic hazard
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Coverage limits- max amount that person can receive when they receive medical attention
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how to solve the problem of adverse selection
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Group policies- businesses that offer insurance and everyone has to join that insurance plan
Elimination Period- waiting period after joining insurance before you can receive benefits. |
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Which of the following statements is FALSE about direct to consumer advertising?
a. Federal Trade Commission monitors DTC advertising of over-the-counter drugs b. Food and Drug Administration monitors DTC advertising of prescription drugs c. DTC advertising by manufacturers is aimed at increasing market share and profits associated with sales of their drugs d. DTC advertising is not monitored by FDA or FTC |
D
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How do we solve the problem of Moral Hazard?
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Coordination of benefits- only 1 insurance will pay at a time if you have multiple insurances
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How do we solve the problem of induced demand?
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Cost sharing-patient share the medical cost with the insurance company. Examples include copayments and co-insurance.
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Step Therapy
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To treat a condition, patient starts at the most cost-effective and safest drug therapy/medicine and then, if the therapy/medication doesn’t work, moves up to a more expensive therapy/medicine
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Generic Substitution:
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a pharmacist-initiated act by which a different brand or an unbranded drug product is dispensed instead of a drug brand that was prescribed by the physician. This means substituting the same chemical entity in the same dosage form for one marketed by a different company
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Therapeutic Substitution:
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a pharmacist-initiated act by which a pharmaceutical or therapeutic alternate for the physician-prescribed drug is dispensed without consulting the physician. This denotes replacement of the prescribed drug with a chemically different drug within the same therapeutic category (eg, hydrochlorothiazide for furosemide; ranitidine for cimetidine; chloramphenicol for erythromycin).
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Drug Utilization Review (DUG):
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The review of physician prescribing, pharmacist dispensing and patient use of drugs with the goal of ensuring that drugs are used appropriately, safely, and effectively. Cost containment mechanism as well.
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Medication Therapy Management (MTM):
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A broad range of activities within the scope of practice of pharmacists and other quality health care providers intended to insure that patients with multiple diseases and on many medications get the greatest benefit possible from their medication regimen.
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Major Responsibility of PBMs?
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(1) Communication between providers and beneficiaries
(2) Agreements with participation pharmacies (3) Monitoring of doctor prescription writing |
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U&C: Usual and customary charge.
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Refers to customers that are paying cash for their prescription. Cost to cash patient (pharmacy retail price) = cost of drug product + dispensing fee (service charge)
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AWP:
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Average Wholesale Price. AWP is what the pharmacy pays for the drug.
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AMP:
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Average Manufacturers Price. AMP is what wholesalers and large hospitals or chain pharmacies will pay for the drug. AMP<AWP
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WAC:
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Wholesale Acquisition Cost. WAC is the price sold to wholesalers (is based on survey of wholesale pricing data rather than manufacturers’ list prices).
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AAC:
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Actual Acquisition Cost. AAC is the actual selling price of the drug to customers
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EAC
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EAC: Estimates Acquisition Cost. Third party payers recognize that a pharmacy’s AAC is less than AWP and therefore don’t want to repay AWP. EAC is the standard set in palce instead of AWP = AWP – x% or WAC + x%.. EAC could also = MAC.
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MAC
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MAC: Maximum Allowable Cost. MAC is the amount paid by PBM for the drug ingredient cost for a multiple-source drug. MAC is usually set at the price of a low-cost generic product without regard as to whether a brand-name or generic product is actually dispensed.
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FUL
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FUL: Federal Upper Limit. FUL is same thing as MAC but just what the government uses.
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cost effectieness analysis CEA
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most commonly used pharmacoeconomic method
a method used to evaluate 2 or more alternatives where the inputs are measured in dollars & the outcome is measured in natural units of effectivenss |
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define comparative effectiveness
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how effective various medical treatments improve health outcomes. this is most easily seen in the case where a treatment is completely ineffective. if research can prove a treatment is ineffective, then inurers could save a lot of money by not covering this type of treatment.
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typical Rx pricing scheme
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typically pharmacies are reimbursed for the cost of the drug product dispensed and a dispensing fee. this dispensing fee should cover the overhead cost incurred by the pharmacy in dispensing the Rx + a reasonable return (or profit) on the pharmacy's investment.
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