- competition (though to bring down cost)

- private insurance

- supply and demand

- profit and loss

- allow for innovation

- price controlled

- more complicated

- leads to greed and spending

1. cost of coverage, save for health care costs

2. incentives for healthy behavior and preventive care

3. role of choice

- both government run programs

- medicare is for those over age 65, elderly or disabled

- medicaid is for poor, low income families

- passed by Obama

- strong consumer protections, provides new coverage options and gives you the tools you need to make informed choices about your health

- increased awareness of the concept of preventive care

- goal of affordable health care COVERAGE, not health care

- reduce premium costs to get 32 million people to gain coverage

- out of pocket:not covered, pay by yourself when sick

- individual: purchased independently and directly from an insurance company, private, insured and administrator, not part of group

- group: offered by employer, union or organization to multiple people

1. HMO: health maintenance organzation-- tight control, closed system, restricted network of providers (no choice), lower cost

2. PPO: preferred provider organization-- looser control, have choice in providers but more costly

3. POS: point of service-- coordinate patient care with primary physician, but more flexible than HMO

- plan that provides comprehensive coverage for high-cost medical events

- high deductible

- limit on out-of-pocket expenses

- couple with health savings or spending account

- common people: young/healthy, self-employed, lower premium, don't believe in insurance

- work with high deductible plans

- employers or employees can con contribute

- tax savings

-may earn interest

- balance from previous years rolls over to next year

 - employers only can contribute

- pay employee's medical expenses

- employers or employees can contribute

- pre-tax money

- can’t be carried over as long as others

- for self employed individuals or small businesses

- only with high deductible plans

- funds in account are used to pay medical expenses

- assures continued coverage for employees and their dependents

- must maintain continuous coverage

- employer group plans with 20 or more employees have to offer for 18 months

- expensive because employer not paying their part of the premium

- allows you to keep coverage when unemployed but will be paying more

- important to have with pre-existing condition to remain part of group insurance

- traditional

- doesn't limit where individual can receive care

- you and plan each pay for a portion of medical expenses after deductible is met

- organized

- specific provider network

- higher cost if go out of network

 - network controls benefits

- keeps costs down

- amount you pay for medical care after deductible is met

- plan will pay 80% so coinsurance is typically 20% of bill

- amount you pay to belong to a healthcare plan

- pay on a regular basis to remain covered

- employers usually pay a portion of premiums

- set time of the year that you can join a health insurance plan or switch without benefit of a qualifying event

- typically late in the calendar year

- care/coverage needed when a patient is majorly injured or diagnosed with disorder requiring expensive treatment

- financially cannot pay for treatment

- under part D, have max total of drug costs, when reached pay small coinsurance or copayment until end of calendar year

- 65 years old

- some disabled

- ESRD- end stage renal disease

- not free

- parts a, b, c and d

- help from state senior health insurance assitance program as well

- AKA medigap

- help with costs of part a and b of medicare

- lettered a to l

- similar to medicare savings plan

- covers hospitalizations, skilled nursing facilities (home etc.) & drugs during hospital stay

- if over 65, premium is free if you or spouse has worked for 10 years

- must be U.S. citizen

- can qualify if less than 65 and disabled for 24+ months

- ALS and ESRD are other coverage exceptions

- professional services by physicians, PA or other authorized people (outpatient)

- durable medical equipment like diabetes

- limited drug coverage

- pay monthly premium- $95-100

- higher for wealthier, low income pay less or nothing through medicare savings program

- AKA medicare advantage or medicare choice

- managed care networks

- optional drug coverage

- ran by private companies, pay premium to them

- other payments go to company too

- certain low income persons

- federal/state program operated by states

- eligibility and services varies from state to state

- pregnant women, blind, disabled and typically children are covered (not parents)

- can have medicare with medicaid

- who receives it- more restricted now since it effects taxes

- what they receive

- how much the providers are reimbursed- more limited since low $$ coming in to those practices

- supplemental security income (SSI)- different in each state but typically blind, disabled, children or elderly

- low income families that meet state requirements

- infants born into medicaid and pregnant women

- adults have eligibility set at lowest allowed by federal law

- no SSI (one of two states)

- children coverage expanded

- mandatory and optional coverage

- ex) prescription, mental health, dental

- 38 optional categories

- state operated program that offers health insurance to individuals who don't have access to coverage and have a serious medical condition that prevents them from purchasing coverage

- expensive medications too

- done by state, but federal version to be created with affordable care act

- veterans affairs- services for military personnel who have served

- eligibility is based on discharge from active military service under other than dishonorable conditions

- administered through department of veterans affairs

- available to active duty service members and retirees of the seven uniformed services, their family members, survivors and others registered in DEERS (defense enrollemnt eligibility reporting system)

- sponsors and family members

- through department of defense

- state childrens health insurance program

- federal/state partnership

- for children whose families make too much to be on medicaid but not enough to purchase insurance

- eligibility and covered services depends on state

- PBM

- some health insurance companies like anthem manage pharmacy claims along with medical claims

- other companies hire PBM to manage for them- leave claims to a specialist

- PBM's and HMO's hire pharmacists

- preferred drug list

- tiered, open or closed

- tier 1 = generics, 2 = preferred brand, 3 = nonpreferred brand, specialty

- patient pays lower cost share with lower tiers

- tiered is most common

- pharmacy and therapeutics committee

- AKA formulary review committee

- used in managed care and institutional settings to review new and current drugs to determine appropriateness for inclusion in formulary

- how formulary list is created

- pharmacists, physicians and other prescribers included

- AKA formulary exception

- requires prescriber to receive pre-approval for prescribing a drug before the drug is covered under the terms of pharmacy benefit plan

- change prescribing behavior, encourage appropriate use of medications and contain costs

- direct coverage of new, high-cost agents to those who have specific medical need

- "NDC not covered" rejection

- encourage the use of therapeutically equivalent, lower cost medications for several different therapeutic drug classes

- may be mandatory and require prior authorization or documented trial period

- plans require patient to change to generic if available

- community pharmacies audited for compliance and charged a fee for not complying

- same as DUE, drug utilization evaluation

- structured, authorized ongoing review of physician prescribing, pharmacist dispensing and patient use of medication

- common in all practice settings, more common in hospital and managed care for cost control

- required with some medicare D plans

- pharmacist or other healthcare provider works with patient to closely manage their therapy and treatment response

- debate on whether or not these drugs should be required: erectile dysfunction, hair growth, reduce aging, morning after, fertility etc.

- plans cut these drugs as a way to cut costs

- medications for chronic conditions

- can be mandatory or major savings if done

- hassle to fill in gaps in community setting

- pricing is unique to mail order

- operate at less costs so cheaper

- option for phone counseling

- plan has limited number of pharmacies it is contracted with

- non participating pharmacy does not agree with terms of insurance plan

- patients will pay full cost if they choose this pharmacy over covered one

- discount after purchase when product manufacturer returns some of money that was paid for the product to the purchaser

- managed care bases rebate off of volume and market share

- rebates can also be given to managed care organization, health plans,  and PBM's

- price for a given drug or service that a pharmacy or other provider would charge a cash-paying customer without benefit of insurance

- gold standard for pricing

- why cash price beats others

average wholesale cost

manufacturers acquisition cost

- formulary management

- therapeutic selection for patients

- MTM and disease management

- prevention service like immunizations

- therapeutic selection for patient

- use of knowledge

- selection of plan that best covers patients medications

- management of patient care

- use of tools given by PBM or insurance companies

- ATTITUDE!!

- ran by private companies

- costs vary by plan

- must enroll to be covered

- prescription coverage or medicare advantage plus prescription coverage

- can apply for "extra help" if you can't afford- partial and full options

- standard: dedcutible, co-pay, coverage gap, catastrohpic coverage

- standard equivalent: different structure, costs same as standard

- enhanced: larger formulary, expensive

 - plans change yearly so reassess

- AKA donut hole

- gap begins after patient and plan spend a set amount of covered drugs

- patient pays 100% of drug cost

- reach true out of pocket spending to get out of gap

- payments from plan member

 - payments from family/friends

- state pharmacy assistance programs

- extra help subsidies

- indian health services

- AIDS drug assistance programs

- brand discount from manufacturer

- group health plans

- government funded programs

- manufacturer patient assistance programs

- third party payment programs

- generic discount from government

- cost from claims not submitted to plan

- annually october 15 - dec 7

- special enrollment: long term care, medicare advantage 5 star plan, LIS, lose creditable coverage or current coverage

- online

- mail

- phone

- don't sign up when eligible or 63 days without coverage

- no creditable coverage and didnt apply when qualified

- additional monthly fee of: 1% x base beneficiary premium per month x # of months since qualified

- non formulary drug approval

- expedited exception- 24 hours

- traditional exception- 72 hours

- appeal- 1 week, goes through review board

- individuals with limited income/resources can get help from federal gov to pay for prescriptions

- low income subsidity

- full LIS: little/no copy, no dedcutible, premium or coverage gap

- partial LIS: low dedcutible and copay, no coverage gap

- consider income and assets

- automatic qualification if: dual eligible for medicare and medicaid, receive supplemental security income (SSI), or medicaid helps pay medicare premiums

- based on income, not assets

- changes based on state

- only helps pay for premiums

- apply yearly

- use to compare medicare plans

- plan comparison, cost analysis, drug alternatives

- need medicare card, zip code, county, DOB and medication list

- low income option from manufacturers

- requirements: source of donation, pharmaceutical representative relationship, & system for collection, tracking and replenishment

- disadvantages: focus on new and expensive products (usually brand), uncertain continuity of therapy, absence of labeling, longevity of samples, and documentation

- donation

- receipt

- inspection

- inventory

- dispensing

- redistribution

- destruction

- returns

- voluntary programs controlled and funded by drug companies/manufacturer

- assist those having difficulty paying for healthcare and prescription drugs

- free or discounted drugs

- each company has own rules and guidelines

- all have income requirements based on poverty guidelines and income verification

- select drug available and how long

- phone refills for regular renewal

- mail patient, physician or pharmacy discount cards

- help with Part D gap

1. find out if medication is offered/covered

2. application form with tax information

3. prescribers signature

4. prescription

5. mail/fax forms depending on company

6. supply shipped from manufacturer or mail order

 7. restart when supply is gone -- frequent reapplication, every 90 days

- paper work - labor intensive

- limited and specific medications (brand name)

- uncertain availability

- lack of consistent process- online is limited

- US citizenship

- limited med supply

- physician must initiate program

- elimination of bulk replacement programs

- income verification

- Rx outreach or xubex

- cheap but varying prices since they buy in bulk

- 90-360 days supply

- without or limited coverage or benefits exceeded

- income requirements on application

- from associations like AAA

- co-pay per prescription or % discount

- varying income requirement

- limited medications

- not all pharmacies accepts

- $4 lists

- generic medications

- not ran through insurance

- certain medications and strengths

- list can change

- disadvantage is pharmacy hopping - no complete profile at one to get best prices

- used in clinics

- need process for dispensing and labeling

- referred to as dispensary instead of pharmacy

- only low cost tablets/capsules, no inhalers/insulin

- limited refill options

- work under a medical director rather than pharmacist

- may have no pharmacist involvement, so opportunities available

- refer to patient if they need affordable healthcare, short term aid, or medication access

- useful contact for service in the community

- county health department

- state department of health and human service

- senior health insurance assistance program

- federal health centers

- extra help and hoosier Rx for pharmD

- private specific disease programs

- community charities

- difference of health status: social and demographic factors like race, ethnicity, gender, income and geographic region

- unjust difference in environment, access/utilization/quality of care, health status, or health outcome deserving scrutiny

- biggest single predictor of health status

- lower household income directly relates to increased risk of chronic conditions

- chronic conditions cause people to fall into poverty when ability to make money is compromised by illness

- main goal of "healthy people"

- cost to society from premature death, disease and disability

- disparities early in life manifest in worse outcomes later

- high-cost health care problems

- between group differences in socioeconomic status

- between group differences in health behaviors

- residential racial segregation

- between group differences in access, use and quality of healthcare services

- stigmatization and discrimination

- refers to the recognition of differences against people within a marginalized population group identified by some attribute

- demonstrated in composite measures of health, health-related quality of life, maternal and child outcomes, mental health, and health behaviors

- from chronic stress, shame, distrust, depression

- institutional, interpersonal, internalized

- from economic and social deprivation, toxic and hazardous conditions, socially inflicted mental and physical trauma, targeted marketing of potentially harmful commodities, inadequate or degrading medical care

- negative discrimination against people with certain physical, behvioral, or social attributes

- isolates people from family, friends and support systems

- barriers against healthcare seeking and social marginalization can lead to poverty and neglect- less prevention, increased susceptibility

- leprosy, IV drugs, mental disorders, epilepsy, HIV/AIDS, STDs, obesity, lung cancer

- immediate distancing from the condition, considered "bad" people

- knowledge, skills, attitudes, and ability of practitioners to provide optimal health care services to patients from a wide variety of cultural and ethnic backgrounds

- AKA: sensitivity, awareness, openness, humility, empathy and fluency

- ability to ineract effectively with people of different cultures

- awareness of ones own cultural worldview

- attitude towards cultural differences

- knowledge of different cultural practices and worldviews

- cross-cultural skills

- avoid stereotypes and communication barriers

- providers learn from patients- everyones success is linked

- closer the communication, better the outcome

- patient must be the enter of the health encounter

- important with increasing demographics of foreign people, better outcomes if provider has recognized, explored and reflected on cultural differences

- want client satisfaction and education

- avoid miscommunication and harmful drug interactions

- slow learning: information extraction is extremely rapid or unconscious, stereotyping, has expecations about individuals based on past knowledge

- fast binding:  used consciously, needs resources

- pay attention to inidividual level- requires attention, hard to do with distractions

- conscious beliefs inconsistent with automatic, unconscious reactions

- implicit cognition- apply automatically activated memories from slow-learning system

- nonverbal- emotions, feelings, behaviors; inconsistent with verbal

- fill in the gaps with beliefs about patients socical category

- rely on stereotypes for outgroup members (not like them)- favor those they are similar to

- awareness

- dont blame yourself

- practice interpersonal interaction skills

- empathy and respect