Explain to a patient what out-of-pocket expenses are and what is included. What impact do these expenses have on a patient’s access to care? What impact do these costs have on popu

public health writing question

Please see attachment. Also, i have attached the class PowerPoint for support. It is very important this assignment is written in a reflective form.
Requirements: Reflective
PHRC 4962 / PHRM 5962 Essentials of Professional Practice II Healthcare Finance Application Reflection Winter Semester 2023 INSTRUCTIONS Use materials covered as part of this course (posted in Canvas and from in-class activities) and from elsewhere to answer the following questions. These questions are reflective inquiries, answer accordingly. In other words, reflect. OUT-OF-POCKET EXPENSES Question #1 Please answer the following questions/statements. Explain to a patient what out-of-pocket expenses are and what is included. What impact do these expenses have on a patient’s access to care? What impact do these costs have on population health? FORMULARIES Question #2 Please answer the following questions/statements. How would you explain a formulary exclusion to your patient? In your experience, are formularies useful? Why or why not? PHARMACY BENEFIT MANAGERS Question #3 Please answer the following questions/statements. What roles do PBMs play in healthcare financing? What are some of the current issues surrounding PBMs? What will be the key impacts, according to you, of the Supreme Court’s ruling in Arkansas vs. PBMs case? Explain your answers.
2 EPP-2 Healthcare Finance Reflection Winter Semester 2023 (continued) AFFORDABLE CARE ACT Question #4 Please answer the following questions/statements. How are circumstances in the healthcare system similar now to the year 2009? How will these similarities drive healthcare reform over the next two years? What do you suggest should be done to help solve some of the health care problems we see now? Support your reflections with facts. Format This application reflection must be posted before the stated deadline. Your reflection should be formatted in the same matter as the questions, with the question number listed and the corresponding answer given below it. Your answer to each question should provide evidence of a deep reflection on the topic asked. Grading This assignment is the comprehensive, end-of-Module assessment for this material; it is worth 14% of your overall course grade. Your efforts to answer these questions should reflect the significance of the assignment. This assignment will be graded on your reflective insight, critical thinking involved in your answers, and relevance to the modules presented. Reflections must be posted by the due date using 12-point, Times New Roman font, and 1.5 line spacing. Due Date Healthcare Finance Application must be posted before Tuesday, 14 February 2023 at 23:55. You may upload this Learning Activity earlier if you wish. Please post this Assessment as Microsoft Word document only (*.doc or *.docx).
1/6/20221A Health Economics Perspective on Public Health??Ioana Popovici, Ph.D.Associate ProfessorDepartment of Sociobehavioral and Administrative PharmacyCollege of PharmacyModule Topics??what is health economics??allocating limited healthcare resources: disease treatment versus health promotion, vaccination, education??healthcare: right or privilege???socioeconomic disparities in health and the development of public health insurance programs??Public Insurance programs (Medicaid, Medicare, CHIP, etc.)??Privateinsurance(PPOs, ACOs, etc.)??socioeconomic disparities in health and the need for health insurance reform (reform efforts, Affordable Care Act)??implications for pharmacists12
1/6/20222Module ObjectivesDiscuss the importance of health economics in the allocation of limited healthcare resourcesContrast health promotion, disease prevention, education, and vaccination with disease treatment from an economic perspectiveRecognize the need for public health insurance programs and the need for health insurance reformCompare and contrast the public health insurance programs in terms of coverage and eligibility (Medicare, Medicaid, CHIP, etc.)Differentiate between the different private health insurance plans (PPO, HMO, etc.) Compare and contrast between private and public health insurance programsDescribe how the ACA impacts healthcare coverage and services in the healthcare system Health??Health ??genetic factors??environmental factors??lifestyle??healthcare??Health -a state of complete physical, mental and social well-being (World Health Organization)??Victor Fuchs (Professor of Economics, Health Research and Policy, Stanford University) ??the greatest current potential for improving the health of the American people is to be found in what they do or dont do for themselves.34
1/6/20223Healthcare in the U.S. ??life expectancy:??1900: 47.3 years??2017: 78.6 years??leading causes of death:??1900: communicable diseases ??influenza and pneumonia, tuberculosis, diarrhea??2017: chronic diseases??heart disease, cancer, accidents (unintentional injuries), chronic lower respiratory diseases??2020: COVID-19 ??3rdplaceHealthcare in the U.S. (cont.)??Healthcare system focus:??diagnosis and treatment of disease ??promotion of health??1979 -Healthy People: The Surgeon Generals Report on Health Promotion and Disease Prevention (Department of Health and Human Services (DHHS) )??Healthy People 2030 vision: a society in which all people live long, healthy lives??Objectives (https://www.cdc.gov/nchs/healthy_people/hp2020/hp2020_topic_areas.htm):??physical activity??nutrition??obesity??tobacco use??substance use??access to health services56
1/6/20224Healthcare Spending in the U.S.??U.S. healthcare spending grew 4.6 percent in 2019, reaching $3.8 trillion or $10,966 per person??$3,800,000,000,000??As a share of the nation’s Gross Domestic Product (GDP), health spending accounted for 17.7%??Spending accounts for 1 of every 9 employees in the U.S.??US healthcare system is the most expensive in the world??5,000 hospitals, 30,000 nursing homes, 800,000 physicians, 2.8 million registered nurses, and 10 million other healthcare workers (300,000 pharmacists)??Exercise: estimate the number of healthcare professionals in Cooper City (population 35,000) based on approximate U.S. population 300 million??By 2028, health spending is projected to reach $6.2 trillion??https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.html??U.S. health spending fell for first time in 60 years in 2020 (2% decline)78
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1/6/20226Healthcare Spending in the U.S.Sources of Financing 1929, 1970, and 2012GetzensHealth Economics & Financing, 5thEditionCopyright John Wiley & Sons, Inc.Factors linked to increases in U.S. Healthcare Spending??Inflation??Exercise: Convert $1 in 1929 dollars to 2021 dollars??Use inflation calculator here: https://data.bls.gov/cgi-bin/cpicalc.pl??U.S. population growth (122 million in 1929 to 330 million today)??Increases in healthcare professionals incomes??Growth facilitated by the shift from individual payments to third-party financing (cost-shifting)??Increases in range and intensity of healthcare services => increases in life expectancy => larger elderly population => more healthcare spending1112
1/6/20227Distribution of Individual Medical Care Expenditures1314
1/6/20228The Concentration of Personal Health ExpendituresGetzensHealth Economics & Financing, 5thEditionCopyright John Wiley & Sons, Inc.1516
1/6/20229U.S. Sources and Uses of Healthcare Funds, 2010GetzensHealth Economics & Financing, 5thEditionCopyright John Wiley & Sons, Inc.1718
1/6/202210Pharmaceutical Spending in the U.S.??Pharmaceutical expenditures -10% of healthcare costs??Fastest growing segment??Expected to increase by 50% in the next decade??Americans spend more on medicines than Japan, Germany, France, Italy, Spain, UK, Australia, New Zealand, Canada, Mexico, Brazil, and ArgentinacombinedSources of Funds for Pharmaceutical ProductsGetzensHealth Economics & Financing, 5thEditionCopyright John Wiley & Sons, Inc.1920
1/6/202211Health Insurance??Healthcare in the U.S. expensive??A small percentage of the population consumes a large share of the total healthcare spent??Who pays for the healthcare of those who are sick???Could the 1-5% with the greatest personal healthcare expenses be able to pay for these without health insurance? Who pays???Is it fair that we contribute to the healthcare expenses of others???What is the reason we agree to contribute to the expenses of others???Risk aversion??Health insurance protects us against this risk of sudden large healthcare expenses??Trade health insurance premium every month for expenses coverage if sick2122
1/6/202212Methods for Covering Risks??Use private savings to pay for current expenses??Individuals trade with themselves at different time periods??Assistance from family and friends??Mutual obligation and reciprocity??Charity as a means of social exchange??Limited for most people??Social healthcare insurance??Contributions are mandatory through the tax system??Private medical care insurance??Individual perspective: trade monthly premium for affordable treatment if/when sick??Societal perspective: risk poolingPrivate Health Insurance Risk Pooling??Club with 100 members??Risk of getting sick: 1/100 (1%)??Healthcare expenditure: $25,000??Annual contribution per member: $250??Money earns interest in a bank account??Every year, money used to pay healthcare expenses of sick member??Societys point of view:insurance is a method of pooling risk such that a persons loss (when sick) is shared across many people??Risk pooling: funds are collected from many people (most healthy) and used to cover for a few peoples illnesses 2324
1/6/202213Health Insurance Terminology??Premiumfor coverage??Agreed upon fees paid for coverage of medical benefits for a defined benefit period??Can be paid by employers, unions, employees, or shared by both the insured individual and the plan sponsor??Deductible??Fixed dollar amount during the benefit period -usually a year -that an insured person pays before the insurer starts to make payments for covered medical services??Plans may have both per individual and family deductibles??Coinsurancerate ??A form of medical cost sharing in a health insurance plan that requires an insured person to pay a stated percentage of medical expenses after the deductible amount, if any, was paidHealth Insurance Terminology (cont.)??Copayment??A form of medical cost sharing in a health insurance plan that requires an insured person to pay a fixed dollar amount when a medical service is received??Maximum plan dollar limit ??The maximum amount payable by the insurer for covered expenses for the insured and each covered dependent while covered under the health plan??Maximum out-of-pocket expense??The maximum dollar amount a group member is required to pay out of pocket during a year??Until this maximum is met, the plan and group member shares in the cost of covered expenses??After the maximum is reached, the insurance carrier pays all covered expenses, often up to a lifetime maximum. (See previous definition.)2526
1/6/202214Healthcare: Right or Privilege???2020: 30 million Americans uninsured??1965: Medicaid and Medicare programs??2010: The Patient Protection and Affordable Care Act??universal coverage -access to healthcare coverage for every citizen??purpose: access to healthcare and improve major gaps in coverage??number of uninsured decreased from 44 million in 2013 to 27 million in 2016??pay for other peoples healthcare???disease cure/treatment versus disease prevention/health promotion??managed care??single-payer plan???decisions based on economic evaluations2728
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1/6/202216Affordable Care Act (ACA)??The comprehensive healthcare reform law enacted in March 2010 ??The law has 3 primary goals:Make affordable health insurance available to more people. The law provides consumers with subsidies (premium tax credits) that lower costs for households with incomes between 100% and 400% of thefederal poverty level.Expand the Medicaid programto cover all adults with income below 138% of the federal poverty level. (Not all states have expanded their Medicaid programs.)Support innovative medical care delivery methods designed to lower the costs of healthcare generally.??https://www.kff.org/health-costs/issue-brief/summary-of-coverage-provisions-in-the-patient/3132
1/6/202217Summary of Coverage Provisions in the Patient Protection and Affordable CareActExpansion of Public ProgramsThe Medicaid expansion to 138% of the federal poverty level ($15,415 for an individual and $31,809 for a family of four in 2012) for individuals under age 65American Health Benefit ExchangesThe creation of health insurance exchanges through which individuals who do not have access to public coverage or affordable employer coverage will be able to purchase insurance with premium and cost-sharing credits available to some people to make coverage more affordableChanges to Private InsuranceNew regulations on all health plans that will prevent health insurers from denying coverage to people for any reason, including health status, and from charging higher premiums based on health status and genderYoung adults will be allowed to remain on their parents health insurance up to age 26The penalties to employers that do not offer affordable coverage to their employees, with exceptions for small employers.3334
1/6/202218Thank you!35
1/6/20221A Health Economics Perspective on Public Health??Ioana Popovici, Ph.D.Associate ProfessorDepartment of Sociobehavioral and Administrative PharmacyCollege of PharmacyModule Topics??what is health economics??allocating limited healthcare resources: disease treatment versus health promotion, vaccination, education??healthcare: right or privilege???socioeconomic disparities in health and the development of public health insurance programs??Public Insurance programs (Medicaid, Medicare, CHIP, etc.)??Privateinsurance(PPOs, ACOs, etc.)??socioeconomic disparities in health and the need for health insurance reform (reform efforts, Affordable Care Act)??implications for pharmacists12
1/6/20222Module ObjectivesDiscuss the importance of health economics in the allocation of limited healthcare resourcesContrast health promotion, disease prevention, education, and vaccination with disease treatment from an economic perspectiveRecognize the need for public health insurance programs and the need for health insurance reformCompare and contrast the public health insurance programs in terms of coverage and eligibility (Medicare, Medicaid, CHIP, etc.)Differentiate between the different private health insurance plans (PPO, HMO, etc.) Compare and contrast between private and public health insurance programsDescribe how the ACA impacts healthcare coverage and services in the healthcare system 34
1/6/20223Public Healthcare Financing in the US-Social Insurance??Insurer = Government??Mandatory contributions??Programs:??Medicare??Medicaid??Veterans Affairs healthcare (VA)??TRICARE ??Indian Health Service (IHS)??Federal Employees Health Benefits Program (FEHBP)??Childrens Health Insurance Program (CHIP)656
1/6/20224Medicare??Established 1965??~ 61 million beneficiaries in 2020??Beneficiaries: Who is eligible for Medicare???>65 years of age?? Within 1 year, over 90% had coverage??Eligibility: everyone with Part A or B -voluntary prescription drug benefits ??Coverage is available through private insurance companies approved by Medicare ??Medicare Part D is financed from general revenues, beneficiary premiums, and state payments ??Premium: varies by plan, averages$30.50 monthly for 2021??Medicare subsidy covers most of that cost161516
1/6/20229Medicare Part D??Two ways to use Medicare Part D:??Medicare prescription drug plans (PDP):??These plans add drug coverage to the original Medicare plan??Must have Part A and/or Part B to join a separate Medicare drug plan??Medicare Advantage Plans (Part C) with prescription drug coverage??A specific Medicare health plan that offers Medicare prescription drug coverage through private insurance companies17What Medicare Part D drug plans cover??All plans must cover a wide range of prescription drugs??Formulary: the approved list of medications covered??Plans include both brand-name prescription drugs and generic drug coverage??The formulary includes at least 2 drugs in the most commonly prescribed categories and classes??Tiers (to lower costs)??Most Medicare drug plans place drugs into different levels called tiers on their formularies??Drugs in each tier have a different cost (a drug in a lower tier willgenerally cost you less than a drug in a higher tier)181718
1/6/202210Medicare Part D formulary tiers??Example:Tier 1??lowestcopayment: most generic prescription drugsTier 2??medium copayment: preferred, brand-name prescription drugsTier 3??higher copayment: non-preferred, brand-name prescription drugsSpecialty tier??highest copayment: very high cost prescription drugs19Medication Therapy Management??CMS has mandated that Part D sponsors offer beneficiaries a Mediation Therapy Management (MTM) program??MTM -free program offered by Part D plans to certain members to help improve their medication use so they can better manage their chronic conditions??Service: face-to face, via phone, mail, email, combination??Targeted beneficiaries:??Have multiple chronic diseases??Taking multiple Part D drugs??Likely to incur annual costs for covered Part D drugs that exceed $3,000201920
1/6/202211Medicaid??Established 1965??Highly subsidized insurance coverage to low-income families, nearly free??71 million Medicaid beneficiaries in 2020??Financed and ran jointly by state and federal governments??State governments have wide latitude to set budgets, determine eligibility rules, and decide how generous their programs will be??~15% of state budgets, 2ndto education??federal government matches state expenditures to help states finance Medicaid, but it also mandates minimum levels of coverage and eligibility??Eligibility vary state by state: ??Financial Eligibility: low income??Non-Financial Eligibility criteria: marital status, number of children, pregnancy, health (disabled, blind), immigration status??Almost all expenses are paid with taxpayers dollarsChildrens Health Insurance Program (CHIP)??Eligibility: children up to 19 years of agewhose parents earn too much to qualify for Medicaid but not enough to afford private insurance??State-federalpartnership that provides health insurance to low-income children??Each state offers CHIP coverage and works closely with its state Medicaid program??Provides comprehensive coverage ??Federal and state governments jointly finance CHIP??Premium:free or families may be required to pay a modest enrollment fee or premiums??6.7 million children were enrolled in CHIP in 2020222122
1/6/202212Veterans Affairs and TRICARE??VA and Tricare provide medical benefits in military including reservists, national guard, military retiree and their dependents??Eligibility:??Any individual who serves on active duty in the armed forces and is discharged other than dishonorably is technically eligible to receive health services from the VA??Majority financed by the federal government??VA operates the nations largest integrated healthcare system (approximately 1,700 hospitals, outpatient clinics, counseling centers and long-term care facilities) with coverage for almost all medical services, such as??Primary care or specialist physician office visits, immunizations, hospitalizations, emergency room visits, medical and surgical supplies, as well as prescription medications??VA provides care to nearly 9 million veterans ??TRICARE ??Insurance that is paid by the government, but uses private doctors and hospitals??Does not require services provided by the VA system??Financed by the federal government23Indian Health Services (IHS)??Provides health benefits to members of federally-recognized Native American Tribes and Alaska Native people??Majority financed by the federal government??Health services are provided directly by the IHS, through tribally contracted and operated health programs, and through services purchased from private providers??Covers 2.6 million American Indians and Alaska Natives242324
1/6/202213Federal Employees Health Benefits Program (FEHBP)??Provides health benefits to civilian federal employees, former employees, family members, and former spouses??FEHBP is financed and managed by the federal Office of Personnel Management (OPM) (federal government) via a managed competition system by allowing qualified insurance companies, employee associations, and labor unions to promote health insurance plans to governmental employees??FEHBP employers pay about 25% of the cost of insurance, the government pays the rest (75%)??FEHB program is the largest employer-sponsored group health insurance program in the world??covers 8 million federal employees, former employees, family members and former spouses25Private Health Insurance Plans??Fee-for-service??Traditional type of insurance in which the health plan will either pay healthcare provider directly or reimburse after claim is filed??When medical attention is needed, the beneficiary can visit the doctor or hospital of their choice??Managed care2526
1/6/202214Managed healthcare ??Managed healthcare plans are an alternative to traditional healthcare plans like fee-for-service plans??Managed healthcare plans allow plan sponsors to negotiate reduced rates for their policyholders with hospitals, medical service providers, and physicians, by including them in the network??In the past few decades, managed healthcare plans have become a popular health insurance choice, as healthcare costs have increased??The type of managed plan you have will dictate how you obtain your medical services. ??Main types of network health plans include:??Health Maintenance Organization (HMO)??Preferred Provider Organization (PPO)??Point of Service Plan (POS)Health Maintenance Organization (HMO)Gatekeeper principlePrimary care provider (PCP) serves as a gatekeeper and must authorize all medical services (visit to specialist)Services not authorized by the PCP will generally not be reimbursedRationale for gatekeeper is to avoid unnecessary expensesPreferred networksPlans will only pay for services provided by healthcare providers that they have contracted with, aka In Network providersPlans will not pay for Out of Network providersPatient premiums are generally lowest among managed care plans2728
1/6/202215Preferred Provider Organization (PPO)No gatekeeperPatients can choose their own providers (specialists) without having to use a designated PCP firstPreferred networks with some out of network coveragePatient can see any healthcare practitioner they want, but they are financially incentivized to see in-network providerse.g., Patient pays 10% to see in-network vs. 50% to see out-of-networkPatient premiums are generally higher than HMO premiumsPoint of Service (POS)??Hybrid PPO-HMO plans??Gatekeeper system like HMO??Primary care physician who makes referrals to specialists as needed??Members who see providers in the POS plan network generally pay a reduced service fee??Members can see providers outside the plan network only if they receive a referral from their primary care physician, plus theyll generally pay a much larger percentage of the cost for out-of-network provider services??Higher copayments for outside plan providers but lower premiums than PPOs2930
1/6/202216Managed care comparisonIntegrated Delivery System(IDS)??A network of healthcare organizations all under the same parent company??Provides all healthcare services to a group of patients, such as within a geographic location??Includes PCPs, physicians, hospitals, pharmacies, and insurers??Note: Not all models include all groups??All work towards the same financial and clinical goals??Main benefit: improved the coordination and quality of care while controlling costs??Do not cover services from out-of-network providers and require referrals for most specialist visits??Example: ??Florida Memorial Health Network??https://www.memorialhealthnetwork.net/3132
1/6/202217Thank you!33

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