Shared Flashcard Set

Details

Delivery of Healthcare Cluster 1/3
cluster 1/3
100
Health Care
Undergraduate 3
01/18/2012

Additional Health Care Flashcards

 


 

Cards

Term
Market driven system
Definition

- competition (though to bring down cost)

- private insurance

- supply and demand

- profit and loss

- allow for innovation

Term
Government run system
Definition

- price controlled

- more complicated

- leads to greed and spending

Term
Considerations when choosing a system (3)
Definition

1. cost of coverage, save for health care costs

2. incentives for healthy behavior and preventive care

3. role of choice

Term
Medicare vs. medicaid
Definition

- both government run programs

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

- medicaid is for poor, low income families

Term
Affordable care act (ACA)
Definition

- 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

Term
Out-of-pocket vs. individual vs. group insurance
Definition

- 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

Term
3 types of managed care plans
Definition

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

Term
High deductible plans
Definition

- 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

Term
Health savings account
Definition

- 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

Term
Health reimbursement accounts
Definition

 - employers only can contribute

- pay employee's medical expenses

Term
Flexible spending accounts
Definition

- employers or employees can contribute

- pre-tax money

- can’t be carried over as long as others

Term
Archer medical savings account
Definition

- for self employed individuals or small businesses

- only with high deductible plans

- funds in account are used to pay medical expenses

Term
HIPAA
Definition

- assures continued coverage for employees and their dependents

- must maintain continuous coverage

Term
COBRA
Definition

- 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

Term
Indemnity/fee for service insurance
Definition

- traditional

- doesn't limit where individual can receive care

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

Term
Managed care
Definition

- organized

- specific provider network

- higher cost if go out of network

 - network controls benefits

- keeps costs down

Term
Network
Definition
group of physicians, hospitals or other providers who participate in a specific managed care plan
Term
Coinsurance
Definition

- amount you pay for medical care after deductible is met

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

Term
Copay
Definition
flat fee you pay for each time you need healthcare
Term
Deductible
Definition
amount you must pay each year before your plan starts paying
Term
Premium
Definition

- amount you pay to belong to a healthcare plan

- pay on a regular basis to remain covered

- employers usually pay a portion of premiums

Term
Open enrollment
Definition

- 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

Term
Primary care physician
Definition
first point of contact with healthcare system, particularly in managed care system
Term
Claim
Definition
- expense that is incurred that submitted to the insurance company
Term
Beneficiary
Definition
the person the insurance coverage is for
Term
Out of pocket maximum
Definition
the maximum amount the beneficiary would pay
Term
Lifetime maximum
Definition
the maximum amount the insurance company will pay out
Term
Catastrophic coverage
Definition

- 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

Term
Medicare specifics
Definition

- 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

Term
Medicare supplemental plans
Definition

- AKA medigap

- help with costs of part a and b of medicare

- lettered a to l

- similar to medicare savings plan

Term
Medicare part A
Definition

- 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

Term
Medicare part B
Definition

- 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

Term
Medicare part C
Definition

- 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

Term
Medicaid specifics
Definition

- 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

Term
Factors impacting cost of medicaid (3)
Definition

- 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

Term
Examples of who qualifies (3)
Definition

- 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

Term
Differences in IN medicaid vs. other states
Definition

- adults have eligibility set at lowest allowed by federal law

- no SSI (one of two states)

- children coverage expanded

Term
Services covered by medicaid
Definition

- mandatory and optional coverage

- ex) prescription, mental health, dental

- 38 optional categories

Term
High risk pools
Definition

- 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

Term
VA benefits
Definition

- 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

Term
TRICARE
Definition

- 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

Term
SCHIP
Definition

- 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

Term
Pharmacy benefit managers
Definition

- 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

Term
Formulary
Definition

- 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

Term
P and T committee
Definition

- 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

Term
Prior authorization
Definition

- 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

Term
Step theory
Definition

- 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

Term
Mandatory generic substitution
Definition

- plans require patient to change to generic if available

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

Term
Drug utilization review (DUR)
Definition

- 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

Term
Medication therapy management (MTM)
Definition

- required with some medicare D plans

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

Term
Lifestyle drugs
Definition

- 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

Term
Mail order pharmacy
Definition

- 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

Term
Non-participating pharmacy
Definition

- 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

Term
Rebates
Definition

- 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

Term
Usual and customary price
Definition

- 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

Term
AWP and MAC
Definition

average wholesale cost

manufacturers acquisition cost

Term
Roles for managed care Rph
Definition

- formulary management

- therapeutic selection for patients

- MTM and disease management

- prevention service like immunizations

Term
Roles for community Rph
Definition

- 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!!

Term
Medicare part D
Definition

- 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

Term
Medicare drug plan options
Definition

- 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

 

Term
Coverage gap
Definition

- 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

Term
True out of pocket cost sources
Definition

- 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

Term
True out of pocket sources that DO NOT count
Definition

- 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

Term
Medicare part D enrollment
Definition

- annually october 15 - dec 7

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

Term
Three ways to enroll in medicare part D
Definition

- online

- mail

- phone

Term
Late enrollment penalty
Definition

- 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

Term
Creditable coverage
Definition
plans from employer or VA that are as good as or better than medicare part D prescription plans
Term
Exception and appeal timing under step therapy and prior authorization
Definition

- non formulary drug approval

- expedited exception- 24 hours

- traditional exception- 72 hours

- appeal- 1 week, goes through review board

Term
LIS
Definition

- 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

Term
LIS qualifications
Definition

- consider income and assets

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

Term
State assistance
Definition

- based on income, not assets

- changes based on state

- only helps pay for premiums

- apply yearly

Term
Medicare part D plan finder
Definition

- use to compare medicare plans

- plan comparison, cost analysis, drug alternatives

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

Term
Drug samples
Definition

- 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

Term
Recordkeeping/audits of drug samples
Definition

- donation

- receipt

- inspection

- inventory

- dispensing

- redistribution

- destruction

- returns

Term
Manufacturer assistance programs
Definition

- voluntary programs controlled and funded by drug companies/manufacturer

- assist those having difficulty paying for healthcare and prescription drugs

- free or discounted drugs

Term
How MAPs work
Definition

- 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

Term
Typcial MAP process
Definition

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

Term
Limitations on MAPs
Definition

- 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

Term
Generic prescription assistance
Definition

- 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

Term
Drug discount cards
Definition

- from associations like AAA

- co-pay per prescription or % discount

- varying income requirement

- limited medications

- not all pharmacies accepts

Term
Discount retail pricing
Definition

- $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

Term
Bulk donations/purchasing
Definition

- 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

Term
Clinics
Definition

- 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

Term
Government run programs for low income patients
Definition

- 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

Term
Health disparities
Definition

- 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

Term
With who do health disparities exist?
Definition
- exist between a group with more resources (gerneral population) and a disadvantaged (less resourced) population group
Term
Socioeconomic health disparities
Definition

- 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

Term
Why is it important to reduce or eliminate health disparities?
Definition

- 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

Term
How do disparities arise?
Definition

- 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

Term
Discrimination definition
Definition

- 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

Term
Levels of discrimination
Definition

- 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

Term
Stigma
Definition

- 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

Term
Stigmatized conditions
Definition

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

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

Term
Culture
Definition
integrated pattern of human behavior which includes thoughts, communication, languages, beliefs, practices, customs, courtesies, rituals, manners of interacting, roles, relationships, and expected behaviors of racial, ethnic, religious, soical or political group
Term
Cultural competence
Definition

- 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

Term
Cultural competence components
Definition

- 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

Term
Concepts in cultural competence
Definition

- 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

Term
Provider bias definition
Definition

- 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

 

Term
Provider bias actions
Definition

- 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

Term
Overcoming bias
Definition

- awareness

- dont blame yourself

- practice interpersonal interaction skills

- empathy and respect

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