2. higher salaries, better working conditions (supply-demand)
3. globalization (immigrants and medical tourism)
4. increasing cost
5. a comprehensive healthcare reform
what do you learn in the MBA?
human resources management and ethics
management information systems
supply chain management
what is the goal of the MBA program?
"to make money today and in the future"
what is the competitive advantage of having an MBA?
cost, quality, speed and flexibility
definition of lean thinking? (in relation to the MBA program)
to become more competitive in today's challenging environment by focusing on value and eliminating all wastes
basically to do more with less
define value and eliminate waste
identify the value stream
flow, pull, perfection
how do we define value in a healthcare company?
by asking several questions:
who are the customers?
what do the customers want?
how do they want it?
when do they want it?
in "lean thinking" concept of the MBA program... what is "waste"?
waste is anything that doesn't add value
we'd like to eliminate all wastes: defects, waiting, overproduction, transportation, inventory, complexity, unused creativity
what is the basic information of the PharmD/MBA program?
it's a unique opportunity to earn an MBA
you complete the MBA as part of the PharmD program
it's composed of foundations and core courses
requires summer courses
additional ~$12K in cost
what are the PharmD/MBA program goals and objectives?
to educate students to assume responsibilities as managers, administrators, consultants and executives in health are systems designed to provide health care to costumers
to become SUCCESSFUL: to be able to make effective decisions
to become PRINCIPLED: to be able to act ethically
to become LEADERS: to be able to demonstrate leadership qualities
to have a GLOBAL PERSPECTIVE: to be able to function effectively in a global business environment
how does the MBA trimester work?
the academic year consists of three 14-week semesters
classes meet 1 night/week (M-Th)
you'll have ~5 week summer break
disadvantages of the PharmD/MBA program?
will not be able to participate in pharmacy didactic electives (5 of the 12 required MBA core courses will be taken instead of electives)
will not be able to participate in selective pharmacy practice rotations in P4 year
may not earn more than 2C's in MBA courses
attain at least a 3.0GPA in MBA program
may be required to withdraw from the program if on academic probation in pharmacy program
what are some admission requirements for the PharmD/MBA program?
full time BJDSOP student in good standing
undergraduate degree from accredited institution
MBA application no later than Feb1 of P1 year
two letters of recommendation (one from PharmD/MBA faculty advisor)
interview with director of MBA program
complete foundation courses
describe the Magna Carta of Pharmacy developed in 1240
the pharmaceutical profession was to be separated from the medical profession
the pharmaceutical profession should be supervised officially
pharmacists should take an oath to prepare drugs reliably, according to skilled art, and in a uniform suitable quality
books listing durgs and other medical services including standards for their preparation and analysis that are recognized by a government authority
what was the first state to issue licenses to apothecaries based on examination by the medical examining board?
what was the first college of pharmacy? (founded in 1821)
PCP = philadelphia college of pharmacy
started in reply to the deterioration of pharmacy and bec the medical faculty was discriminating against pharmacists saying that they weren't qualified
who is the founder of american pharmacy?
william proctor jr.
he was the 1st secretary of APhA
and graduated from PCP in 1873, remember, PCP = 1st college of pharmacy
pcp=philadelphia college of pharmacy
who believed that scientific foundation of pharmacy should first be through didactic, then practical; "school first, then practice"; he was dean at the university of michigan; ideas were rejected until the turn of the century; before his idea = apprenticeship, limited classwork at the pharmacy school
albert b. prescott
what drug law made sure that medications adhered to certain criteria?
1906 Pure Food and Drug Act
effect on profession: (1) compounding was individualized but this era hurt the pharmacist role, not relied for compounding anymore bec of pharm industry; (2) knowledge: was getting harder and harder to keep up with the side effects of the drugs
who developed the 3 basic characteristics of pharmacy as a profession; tried to reestablish the profession of pharmacy; was a pharmacist and professor at the univ of florida
charles d. hepler
his 3 hallmarks:
1. the services offered are closely linked to major human values, such as health, property and religion
2. the services require a degree of knowledge, skill and understanding beyond those possessed by ordinary people of the day and beyond a layman's ability to evaluate
3. the services are inherently personal or individualized in nature, meaning that they cannot be readily standardized or mass produced
what was the "9th floor project" at UCSF?
goal: wanted pharmacists at the floor of the hospital
so that everything involved with distribution would fall with the pharmacist
provided a non biased and easily available source of drug
to design and conduct studies with physicians and nurses
what is the "mill's report"?
an AACP comissioned study of pharmacy, headed by Dr. John Mills
14 recommendations including:
acceleration of development of clinical sites for pharmacy faculty
development of national examination for licensure (NAPLEX)
increased movement toward making pharmacy a knowledge based clinical profession
creation of a small number of clinical scientist programs in schools of pharmacy at the PhD level
creation of a board of pharmaceutical specialties with APhA to recognize specialty practices in pharmacy and certify individuals in those specialties
definition of pharmaceutical care defined by hepler and linda strand?
1. was defined as providing successful drug therapy: pharmaceutical care is the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient's quality of life. these outcomes are: (1) cure of a disease, (2) elimination or reduction of a patient's symptomology, (3) arresting or slowing of a disease process, (4) preventing a disease or symptomology
2. talks about team approach, pharmacist as being part of the team and the pharmacist is the drug expert: pharmaceutical care involves the process through which a pharmacist cooperates with a patient and other professionals in designing, implementing and monitoring a therapeutic plan that will produce specific therapeutic outcomes for the patient. involves (1) identifying potential and actual drug related problems, (2) resolving actual drug related problems, (3) preventing potential drug relating problems
3. key: direct relationship to the patient and directly responsible for the patient: pharmaceutical care is a necessary element of healthcare & should be integrated with other elements. pharmaceutical care is however, provided for the direct benefit of the patient, and the pharmacist is responsible directly to the patient for the quality of that care. the fundamental relationship in pharmaceutical care is a mutually beneficial exchange in which the patient grants authority to the provider and the provider gives competence and commitment (accepts responsibility) to the patient.
4. key: components all there no matter where you are: the fundamental goals, processes and relationship of pharmaceutical care exist regardless of practice setting
what is the asheville project in 1997?
decreased cost of insure their employees by developing a pharmaceutical care program at the retail setting
worked with patients to get disease states controlled and it worked to decrease cost!
employees called out work and decreased drug cost for the city
pharmacist showed that we have the education and knowledge to work with patients and get their disease states controlled
describe: medicare prescription drug, improvement and modernization act of 2003
MTM became part of the new medicare part D prescription program after the asheville project
required medication therapy management (MTM)
requires MTM services be provided to high risk patients with the goals of enhancing patient's understanding of appropriate drug use, increasing adherence to medication therapy and improving the detection of adverse drug effects
general duties and training: community pharmacy
works in a variety of settings: retail, independent, large box and grocery
long hours, standing a lot and can be stressful
must like to help people and mutitask
general duties and training: long term care
setting: nursing homes
education: pharmD and sometimes residency required
need CGP: certification in gerontology pharmacy preferred
provides a monthly drug review on all patients
general duties and training: managed care pharmacy
setting: HMO or PPM (ex. kaiser permanente)
education: pharmD and sometimes residency, depending on the position
advantage: no insurance issues
general duties and training: primary care (ambulatory care)
setting: with doctor and patients by appt
education: pharmD and residency
doctor recommends appt with pharm to adjust patient meds
downside: only associated w/ school of pharm, hard to pay you a competitive salary
general duties and training: academic pharm
education: residency required!!!
day to day is mixed: research, teaching or service
pro: no weekend or holidays
general duties and training: drug info pharm
setting: hospital environment
general duties and training: medical liason pharm
education: experimental and clinical experience
set up from a drug sales rep (usually business majors or nurse majors)
education, can be med shcool or PA, but have had clinical training
talks to doctor and gives more in depth detail compared to drug rep
hard position to get in
main goal/focus of: APhA American Pharmacist Association
organization congress expects to speak for pharmacy
serves as home for board of pharmaceutical specialties (BPS), pharmacy services support center (PSSC) and pharmacy technician certification board (PTCB)
main goal/focus for NCPA national community pharmacist association
program for community pharmacists and other on their behalf on capitol hill
worked with industry partners to form the 4th largest medicare prescription drug program, community CCRx, aggressive MTM
main goal/ focus for ACA american college of apothecaries
members focus on professional side of practice rather than business aspects
must own or work in pharmacy devoid of commercial trappings or advertisements
sell primarily prescription and non prescription drugs, medical supplies, etc
main goal/focus for ASHP american society of health system pharmacists
represents pharmacists who practice in hospital and health systems
responsible for accreditation of residency programs
offers membership sections based on area of practice
main goal/focus for ASCP american society of consultant pharmacists
members are experts in GERIATRIC pharmacotherapy
main goal/focus for ACCP american college of clinical pharmacists
emphasizes experience in practicing or teaching patient oriented clinical pharmacy
main goal/focus for AMCP academy of managed care pharmacy
members work in HMOs, managed care groups, and pharmacy benefit management companies
main goal/focus for ACPE accreditation council for pharmacy education
accrediting body for pharmacy schools
funds come from fees charged to pharmacy schools
main goal/focus for AACP american association of colleges of pharmacy
represent interest of the administration and faculties of the colleges of pharmacy
main goal/focus for NABP national association of boards of pharmacy
represents the state boards of pharmacy
helps to increase consistency in pharmacy laws from state to state
traning: pharmD, active license, 3 yrs practical experience/residency (1/2 in nutritonal support); NSPSCE certification, specifically for nutritional support!
general duties and training: hospital pharmacy
duties: provide indirect patient care, work with doctors to decide which meds and therapies are appropriate for patient's condition; prepare/dispense meds; provide info; drug expert in hospital; monitor drug therapy
training: pharmD, BS of pharmacy
general duties and training: compounding pharmacy
duties: individualized prescription medication (specialized dosage, medication delivery, non active ingredient allergies, discontinued or short supply drugs, vet patients)
training: BS or PharmD degree, active license; 3 day course of special compounding skills
general duties and training: critical care pharmacy
duties: responsible for managing meds for critically ill paitients; contributes to patient rounds with care teams; participates in cose, preparing meds and life support; educates MDs, residents, fellows and nurses on drug info
training: pharmD, 2 yrs residency
general duties and training: poison control pharmacy
duties: emergency calls and suggest action plans for dealing with hazardous chemicals and harmful drug interactions
training: pharmD, residency or equivalent experience (one and 2 yr residencies/fellowships in clinical toxicology); certification as a specialist in poison info; certification by the american board of applied toxicology
general duties and training: psychiatric pharmacy
duties: drug monitoring, providing info, dispensing, compounding, working w/ other health professionals
training: pharmD, 2 yrs of residency or 4 yrs of practice (50% related to psychiatric pharm); pass board certified exam BCPP and recertification required every 7 yrs; active licence
general duties and training: veterinary pharmacy
duties: compounding; prepare heartworm preventatives, antiparasitic meds, hormone therapies; pain management; primarily deal with owners and vets; teach
training: license, pharmD; background in animal husbandry
general duties and training: pediatric pharmacy
duties: dispense/distribute meds; monitor stage of medication therapy; catering dosage calculations to the specific needs of children; prepare IVs; work with other healthcare prof; advising, counseling and consulting
training: pharmD, 1 year general residency + specialty residency in ped pharm; active license
general duties and training: infectious disease pharmacy
duties: manage infectious disease pharm; educate; monitor; research
training: pharmD, active license; PGY1 and PGY2 preferred; BCPS certification; fellowship possible
general duties and training: public health services pharmacy
duties: highly collaborate with healthcare prof; promote preventative healthcare; assist in disaster and underserved areas; help in healthcare legislation
training: pharmD or BS in pharm; active license; additional degree option: MPH
general duties and training: oncology pharmacy
duties: supportive care, anitbiotic therapy, managing patient's organ systems; administrative duties
training: pharmD, active license; PGY1&2; must pass the oncology pharm specialty certification exam; experience
general duties and training: nuclear pharmacy
duties: compound radiopharmaceuticals; handling radiopharm and hazardous waste materials; perform checks on instruments and equipment; laboratory testing on new radiopharm and compounding procedures; couseling and monitoring
training: pharmD; residence preffered; >200 hrs of training an basic radioisotope handling; >500 hrs of experience in handling unsealed radioactive material
general duties and training: operating room pharmacy
duties: prepare and overee meds in OR; trach controlled substance used by the anesthesia providers and surgeons; work with other healthcare prof; educator/researcher
training: active license, pharmD, hospital pharm experience; experience in unit doses and or IV admixtures
general duties and training: military pharmacy
duties: manage; advice doctors and patients; train; consult on durgs and meds; check supplies; record keeping
training: must be US citizen or permanent US resident; must be 21-42 yrs of age; active license; must graduate AMEDD officer basic course; must complete additional courses to hold positions at the lieutenant colonel level and colonel level; pharmD
definition of a pharmacy residency
an organized, directed, postgraduate training program in a defined area of pharmacy practice
residencies exist to train pharm in a professional practice and management activities; in depth experience
PGY1 vs PGY2 residency?
PGY1: builds upon knowledge, skills, attitudes and abilities gained from an accredited prof pharm degree program; 1st year enhances GENERAL competencies
PGY2: builds upon the competencies established in postgraduate year 1 or residency training; focused in a SPECIFIC area of practice; increases depth of knowledge, skills, attitudes and abilities
definition of fellowship?
a research fellowship is a directed, highly individualized postgraduate training program designed to prepare the participant to function as an independent investigator
a progression of post graduate training that takes the trainee from the clinical environment into a research arena
reasons for doing fellowship?
if research is expected to be a major portion of your professional career (pharm faculty positions often require residency training; if you want to be more focused on research and teaching; appropriate for research positions)
will expose a pharmacist to protocol and grant development as well as techniques for completion of clinical investigation that's not found in residency training
prepares an individual to be an independent investigator
the 4 hierarchies of moral reasoning as described by beauchamp and childress: ethical theories are derived from princliples, which are derived from rules, which are derived from particular judgements and actions
people 1st learn about moral reasoning as children, observing their own and other's actions and developing opinions about right or wrong
these opinions are codified into RULES, which kindergarten and elementary school children use as good vs bad view of the world
as the child matures, they develop principles of behavior that act as guides in dillemmas
finally, ethical theories are developed by an individual to guide bejavior when rules and principles may conflict with one another
APhA codes and principles? 5
AUTONOMY: an action is right if it respects the autonomy, or independent choice of others
VERACITY: telling the truth is right
FIDELITY: keeping promises, commitments, contracts and covenants is right
AVOIDING KILLING: taking of human life is wrong
JUSTICE: fair distribution of goods and harms is right
APhA code of ethics? 8
1. a pharmacist respects the covental relationship between the patient and pharmacist
2. a pharmacist promotes the good of every patient in a caring, compassionate and confidential manner
3. a pharmacist respects the autonomy and dignity of each patient
4. a pharmacist acts with honesty and integrity in a professional relationship
5. a pharmacist maintains professional competence
6. a pharmacist respects the values and abilities of colleagues and other health professionals
7. a pharmacist serves individual, community and societal needs
8. a pharmacist seeks justice in the distribution of health resources
having independent choice
5 elements of informed consent: competence, disclosure of info, understanding info, voluntariness and authorization
nonmaleficence vs beneficence
nonmaleficence means "at least, do no harm", refers to not taking actions that would inflict harm
compare to BENEFICENCE: refers to taking actions that will do good
how do we identify ethical issues and work through them? FOUR BOXES... outline?
1. Medical Indications: Principles of
Beneficence and nonmaleficence (to do no harm)
2. Patient References: Principle of Respect
3. Quality of Life: Principles of Beneficence
and Nonmaleficence and Respect for Autonomy
4. Contextual Features: Principles of Justice
part 1 of the 4 boxes of ethics: Medical Indication – principles of beneficence and nonmaleficence
What is the patient’s medical problem?
Is the problem acute? Chronic? Critical? Reversible? Emergent? Terminal?
What are the goals of treatment?
In what circumstances are medical treatments not indicated?
What are the probabilities of success of various treatment options?
In sum, how can this patient be benefited by medical and nursing care and how
can harm be avoided?
part 2 of the 4 boxes of ethics: Patient References: principles of respect for autonomy
Has the patient been informed of benefits and risks, understood this
information, and given consent?
Is the patient mentally capable and legally competent, and is there evidence of
If mentally capable, what preferences about treatment is the patient stating?
If incapacitated, has the patient expressed prior preferences?
Who is the appropriate surrogate to make decisions for the incapacitated
Is the patient unwilling or unable to cooperate with medical treatment? If so,
part 3 of the 4 boxes of ethics: Quality of Life: principles of beneficence and nonmaleficence and respect for autonomy
combines 1 and 2
What are the prospects, with or without treatment, for a return to normal life,
and what physical, mental, and social deficits might the patient experience
even if treatment succeeds?
On what grounds can anyone judge that some quality of life would be undesirable
for a patient who cannot make or express such a judgment?
Are there biases that might prejudice the provider’s evaluation of the
patient’s quality of life?
What ethical issues arise concerning improving or enhancing a patient’s quality
Do quality of life assessments raise any questions regarding changes in
treatment plans, such as forgoing life-sustaining treatment?
What are plans and rationale to forgo life-sustaining treatment?
What is the legal and ethical status of suicide?
part 4 of 4 boxes of ethics: Contextual Features: principles of justice and fairness
Are there professional, interprofessional or business interests that might
create conflicts of interest in the clinical treatment of patients?
Are there parties other than clinicians and patients, such as family members,
who have an interest in clinical decisions?
What are the limits imposed on patient confidentiality by the legitimate
interests of third parties?
Are there financial factors that create conflicts of interest in clinical
Are there problems of allocation of scarce health resources that might affect
Are there religious issues that might influence clinical decisions?
What are the legal issues that might affect clinical decisions?
Are there considerations of clinical research and education that might affect
Are there issues of public health and safety that affect clinical decisions?
Are there conflicts of interest within institutions and organizations
pharmaceutical care practice requirements
trusting relationship (confidence, reliability, and continuity)
basically, must have the education, commitment and patient's trust
MTM: pharmaceutical care in community pharmacies 2003
MTM - medication therapy management, need to look at complete regiment and see what else we can do
go above and beyond
enhance the understanding of appropriate drug use, increase adherence, improve ADE (adverse drug effect) detection, 5 core elements
rationale for pharmaceutical care
#1 reason = pharmacists are the most accessible health care professionals
PC helps eliminate unnecessary costs by improving medication use (optimal care)
adverse drug reactions are responsible for longer hospital stays, higher costs and morbidity and mortality
preventable drug interactions account for 1/3 of adverse drug events annually in the US
when should pharmacists intervene?
before, during and after medication selection
before and after the patient has started taking the medication
when a patient notices a problem
constant routine monitoring is necessary
pharmaceutical care cycle
identify the problem --> set goals/outcomes --> develop a care plan & educate --> monitor and follow up --> back to beginning (identify the problem)
barriers enhancing adverse effects
limited access to patient medical info
limited communication between health care prof
lack of time with patient
lack of proper resources
patients belief in competency of pharmacist
JCAHO joint commission on accreditation of healthcare organization
accredits health care organizations
recognized the prevalence of med errors and drafted new med standards with a greater emphasis on medication safety
look alike and sound alike meds, reagents and chemicals must be segregated in all areas of health care org
prescribers need to specify the indication for use as part of the order
institute for safe medication practices ISMP
nonprofit org educating the health care community about safe med practices
independent practitioner review that focuses on med error prevention in the US
usually passes the confidential info to medwatch
focus = prevention
FDA medical products reporting program
reports serious AE and product problems to FDA either directly or via manufacturer
designed to educate all health professionals about critical importance of being aware of, monitoring for and reporting adverse events and problems to FDA/manufacturer; and to ensure that new safety info is rapidly communicated to the medical community, to improve patient care
definition of health by the WHO (world health organization)
"state of complete, physical, mental and social well being and not merely the absence of dsease or infirmity"
why is the US healthcare system unique?
the US spends the highest amount of money (GDP) in the whole world, not by the actual amount, but by the percentage of how much we have
we're one of the only developed countries with NO comprehensive system for paying for health services for residents
in the US, providing health care services has LARGE PROFITS!
distribution and access to health services is significantly uneven
what are the 5 main components of the health care system?
1. personnel: human providers of care
2. institutions: hospitals, clinics, long term care facilities, pharmacies, anywhere where care is sought or received
3. financing mechanisms: how is our patchwork system paid for
4. firms producing 'health commodities': pharmaceutical industries that produce meds, companies that provide equipment to hospitals
5. research and educational institutions that produce knowledge and health personnel: ex: bjd sop
reasons for increased life expectancies?
1. changes in standard of living: hygeine, diet, nutrition, housing
2. advances in public health
3. progress in medical practice
main problems in the US health care system?
1. rapid increases in health care cost
2. access to care is limited
3. physician oversupply and under-supply of other health professionals (ex shortage of nurses)
4. fraud and abuse (other countries have a comprehensive system that prevents fraud and abuse, our patchwork system allows people to fit through the cracks and steal $$$)
5. waste and unnecessary care given
6. fragmentation of care (duplication of care and services, go to hospital bec of drug interactions bec prof aren't aware of other stuff patient is on)
where does the us healthcare system $$ go? who are the biggest things???
BIG PERCENTAGE goes to hospitals
then other health care professionals (not that impt)
pharmaceuticals are 4th (prescriptions)
General Models of Health Care Systems: Socialized
one payer... usually the govt is paying for everything
mostly private providers... don't work for the govt but are paid by the govt... so private hospitals or pharmacies paid by govt still
allows private enterprises to work within the health care system
general models of health care system: socialist
one payer = government, the govt owns all the hospitals and clinics, it runs everything that relates to health care
most providers owned or employed by govt
general models of health care system: decentralized national
mostly private providers
what the US health care system is!!!
what type of health care model does US, china and england have?
US is decentralized national
CHINA has a socialist health care structure but partly decentralized bec it has private health care providers!!! govt only pays some not all!
ENGLAND has socialized and socialist.... govt operates almost all the hospitals, physicans offices are mostly private
CANADA is socialized... govt pays for nearly everything (by provinces, not federal), lots of private health care prof
so strong relationship between political structure and health care but not exact
HAWAII state based attempt at health care system
leader in health care reform: one of the 1st states to implement change
prepaid health care act of 1974
all employers have to provide insurance coverage with a standard benefits coverage, employee paid some and employer paid the rest
state health insurance program 1989coverage for 'gap group,' (those self insured or out of work, those that fell in the cracks)basic benefits package emphasizing prevention and primary care
limited catastrophic benefits
created large purchasing poolprovides common benefit package at a capitated rate
5MC plans awarded contracts
if you get lower than poverty level (<133%), govt pays for it
TENNESEE state based attempt at health care system
TennCare: asheville project
medicade reform to control medicaid costs, exted coverage to those w/o employer sponsored plans
problem: caused certain insurance companies to go down =(
more services than original medicaid
MASSACHUSETTS state based attempt at health care system
mandatory healthcare for all residents!!!
law requires everyone to possess health insurance
state gov helps those who can't afford to pay for plan themselves
trying to control costs via global payment (per person per month system payments)
affordable health care act of 2010... 2010 implementation
kids <26 allowed to stay on parents insurance (major group w/o insurace = college students and those that just graduated.. try to fix some of this)
medicare reimbursement for doughnut hole ($250)
doughnut hole... seniors that fall in this hole can get reimbursement
high risk pool for pre-existing condition people w/o insurance for >6 months (all those that can't buy insurance cause insurance won't cover them... create high risk pool and sell them insurance, govt will cover those)
no lifetime caps on coverage
restrictions on annual limits (we'll only pay $$ for this condition, etc. govt put restrictions on what annual limits insurance comp can have)
health plans provide free preventative care (typical screening things we have to pay copay on are now free, no more copay)
cannot deny children with pre-existing conditions
cannot take away coverage for getting sick
affordable health care act of 2010... 2011 implementation
reward providers for quality care rather than volume
pharmaceutical manufacturer free
OTC reimbursement through medical savings account not allowed
medicare reimbursement for 'doughnut hole' at 50% for brand name drugs (instead of just $250)
affordable health care act of 2010... 2012 & 2013 implementation
reward hospitals based upon quality of care
medical savings accounts limited to $2500 per year contributions
affordable health care act of 2010... 2014 implementation (big one)
individuals required to carry insurance (remember: from massachusets!!!)
cannot base coverage or premiums on health status
annual limits on benefits banned (moved from restrictions to ban!!!)
medicaid expansion to cover more people and insurance exchanges
essential benefit package
health care financing: voluntary, out of pocket
get sick, go to provider, pay out of pocket
where does this occur in our health care system? the uninsured, OTCs fall under this
health care financing: voluntary reimbursement
go to provider, see provider, still paying out of pocket (so same as 1st)
but now... you're paying provider entire cost, submit receipt to insurance co and get reimbursed
where do we see this in US healthcare system? the original way US health insurance was set up, some private insurers
health care financing: public reimbursement
pay provider directly and then...
instead of submitting to a private insurance company, to a public insurance company (basically govt owned or operated!)
then get reimbursed
not really seen in the us heath care system
health care financing: voluntary contract
person goes to providers
instead of paying providers directly, now the insurance is reimbursing the providers
providers submit receipt/claim to insurance company to get reimbursed! not the patient
may have to pay some fees like copay (that's why it's not on slide)
model for nearly all private insurers today
health care financing: public contract
"person goes to providers instead of paying providers directly, now the insurance is reimbursing the providersproviders submit receipt/claim to insurance company to get reimbursed!"
put in medicaid/medicare = public contract instead of private providers
another word for it = socialized medicine
health care financing: voluntary integrated model
integrated because insurer = provider
the payer and the provider are one and the same, no longer separate
HMOs like kaiser permanente
health care financing: public integrated model
govt body is the payer and provider, the same
example? VA hospital system
incentives and risks of health care: FFS (fee for service)
if you're the provider and you get paid for each service, you want to provide more service (increase utilization)
provider has no incentive to hold down the cost
the insurance carriers then assumes all the risk
this is how retail pharmacy works!!!
incentives and risks of health care: capitation
because insurance gives provider set amount of payment each month
want to see as little as possible!!! decrease utilization
provider wants to hold down the cost, get more profit!
provider and insurance carrier split risk
ex. if get a lot of visits that month, can make less $$$ than how much they were given
general gist of medicare part A vs medicare part B vs medicare part D?
A: covers hospital bills; for hospital and skilled care facilities (covers ALL emergency services in all hospitals)
B: covers medical insurance coverage; supplemental medical insurance for physicians
D: covers prescription drugs
Medicare part A which covers hospital bills, Medicare Part B which covers medical insurance coverage, and Medicare Part D which covers prescription drugs
what does part A cover for inpatient hospital care?
part A is for inpatient HOSPITAL care
benefit period = 90 day medical necessity period, renewable (starts at 90 days available after a break from a hospital visit)
if more than 90 days, pull from the 60 day lifetime reserve which is non renewable
190 days of inpatient psychiatric care in person's lifetime
covers semiprivate room, meals, nursing care, drugs, lab tests, xrays, OR
BLOOD: pay for or replace 1st 3 pints of blood/year, if need more than 3 pints, can use B to cover it
what does part A cover for a skilled nursing facility care?
100 days of care per benefit pay period
semiprivate room, nursing care, meals, drugs, rehabilitation services, medical supplies & equipment
previous hospital stay: at least 3 days stay and within 30 days of discharge
what does part A cover for a home health care facility?
no time or visit limits, intermittent
skilled nursing care, physical therapy, occupational therapy, speech therapy, home health aide services, medical social services, medical supplies, durable medical equipment
what does part A cover for hospice care?
if life expectancy is <6 months and you waive right to a traditional treatment, at home typically; for those declared terminally ill
basically just for pain and symptom relief
physician, nursing care, couseling, homemaker, short term respite care (5 days)
small copayment on drugs
small coinsurance inpatient respite care
TERMS: deductable? copayment? coinsurance?
deductable = out of pocket expense you have to pay before insurance kicks in
copayment = fixed dollar amount for service
co-insurance = fixed percentage of the total amount of the bill
is part B free???
No, has a monthly premium and a yearly deductable, can be purchased without part A
not required to get part B
if you don't qualify for part A, can purchase part B
"medicare approved charges" providers accept "assignment" or not
if accept assignment: agree to medicare fee schedule, they will only charge medicare fee sched and patient owes 20% of that bill
if assignment not accepted: paid less by govt and the provider is allowed to charge the pt more! overall, they'll get paid more
basically... medicare pays 80% and patient pays 20%
what does part B cover?
outpatient hospital services
xrays and lab tests
physical and occupational therapy
home health care
drugs and biologicals (ex immunizations)
durable medical equipment
ambulatory care (walk yourself in and walk yourself out)
outpatient prescription drugs
limited coverage for stuff like chiro, podiatrist, opto, dental
joint federal-state program!
currently all states participate
purpose is to provide health care to the indigent (poor)
what mandatory services does medicaid provide?
hospital - inpatient & outpatient
laboratory & xray
rural health clinic
EPSDT (preventative services)
what optional services does medicaid provide?
optometrist, dental, ICF, prescription meds, dentures, eyeglasses, medicare part B, medicare part A supplemental
health maintenance organization act of 1973
catalyst for managed care growth
provided money for start up HMOs
required employers with >25 employees to offer an HMO as a health alternative
what are the 4 characteristics of managed care? (MCOs)
different types of MCO are set by these 4 characteristics
1. risk bearing (who bears the risk)
2. physician type (working for insurance co or private)
3. relationship exclusivity
4. out of network coverage
what are the 3 main types of MCO's???
the only voluntary integrated one
staff - employed physicians
group - exclusive contract with large medical group
network - nonexclusive contracts with large medical groups
IPA - non exclusive contracts with many solo/small groups physicians
2. PPO - affiliations of providers seeking contracts with insurance
3. POS - pick provider at time of service; hybrid plans
purpose of gatekeeper is to reduce costs
PCP primary care physician coordinates all care, authorizes medical services and authorizes referral to specialist
PBM? pharmacy benefits managers?
administer Rx coverage by claiming processing and contracting with pharmacies to provide services
Medicare part D (prescription drug benefit)
comprehensive prescription drug coverage
anything else that's not covered by medicare part B
has a monthly premium ($30-35) and a yearly deductable
patient has 25% coinsurance
has a doughnut hole!!! (between $2250-3600 covered slowly by the patient)
so before 2250 and after 3600, covered by insurance