What I learned week 12

What I learned week 12

Dr. Kahn gave us an introduction to the different government drug payments plans such as Medicare Parts B&D; Medicaid and the VA system. She also reinforced our knowledge of pharmacy benefit managers, and P&T committees, which we have discussed before with other speakers and learned upon in several readings.

Dr. Kahn began the discussion talking about risk which I thought was very interesting. There are two types of risk, pure and speculative. Pure risk is a category of risk in which loss is the only possible outcome, such as a fire. Then there is speculative risk, which is a category of risk where there is a chance of gain as well as loss; such as gambling or starting a new business. Thus, pure risk is insurable to an extent whereas speculative risk is not insurable. You cannot buy insurance before you gamble to protect your money, it doesn’t work like that. Dr. Kahn started the conversation with these two definitions to further elaborate on the topic of health insurance in the U.S and the impact of chronic diseases on health spending. “Amount spent each year treating patients with one or more chronic disease. Chronic illnesses account for 75% of the $2.2 trillion we spend on health care each year in the U.S. Investing in prevention and disease management will save lives and money now and well into the future” And, in the U.S we insure chrinic illness with health coverage plans such as Medicare Parts B&D; Medicaid and the VA system. This ties back to risk, so is chrinic disease pure risk or speculative risk. One can say both, but here Dr. Kahn’s opinion was that chronic diseases is speculative risk and in fact it should not be insured. Chronic Diseases: The Leading Causes of Death and Disability in the United States. Chronic diseases and conditions—such as heart disease, stroke, cancer, type 2 diabetes, obesity, and arthritis—are among the most common, costly, and preventable of all health problems. Many of these diseases are completely preventable with healthier eating, exercise, tobacco and drug free lifestyles as well as other healthy life choices such as frequent doctor visits. Thus, the U.S should not insure chronic illness because we are promoting unhealthy lifestyles. If we continue to insure these bad decisions, Americans are going to continue to lead unhealthy lifestyles because they know they have health coverage as a crutch. If that crutch wasn’t there and if Americans truly faced the expenses and consequences of chronic illness, they would lead healthier lives and chronic disease numbers would rapidly shrink.

I was more interested in the discussion about Medicare Parts B&D; Medicaid and the VA system simply because I wasn’t as knowledgeable about the topic. Dr. Kahn began Thursdays discussion with Medicaid because it’s] simply easier to understand. Medicaid is the largest health care program in the U.S with 60 million low income enrollees. Medicaid is join financed by the federal government and the states, so the federal government matches state spending 1:1. Medicaid is also administered by the states, they set their own policies for eligibility, enrollment, spending but hey must follow broad general guidelines set forth by the federal government. The state controls what will go into the formulary, and there is only formulary per state. Something I thought was interesting is that one would assume, okay every state has their own Medicaid formulary so there should be 50 formularies, but no. In fact, there are 56 Medicaid programs, this is because each territory also had some Medicaid program/formularies as well as the capital city of the U.S, Washington D.C. So, all 50 states, Washington D.C and the five U.S territories, America Samoa, Guam, Northern Mariana Islands, Puerto Rico and the U.S Virgin Islands, equal 56 Medicaid programs.

Guide to the 5 U.S foreign territories:

Dr. Kahn then went into Medicare, which is more complicated. Part B was established in 1966 which covered medical insurance: physician services, outpatient hospital care, x-rays, laboratory and diagnostic tests, dialysis, vaccinations, chemotherapy, and durable medical equipment. Part D was established in 2006 which covers prescription drug coverage. An issue we discussed with Part D Medicare is the coverage gap. Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means there's a temporary limit on what the drug plan will cover for drugs. “Not everyone will enter the coverage gap. The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs. In 2017, once you and your plan have spent $3,700 on covered drugs, you're in the coverage gap. This amount may change each year. Also, people with Medicare who get extra help paying Part D costs won’t enter the coverage gap (U.S Centers for Medicare & Medicaid Services).” I considered the future for this coverage gap and how it may affect my loves ones such as my grandma who is using Medicare services. Basically, what I found is that there is a trend in utilizing generic drugs more and more; this ultimately slows down the accumulation of money in hopes of never reaching the peak of $3,700. The percentage people are saving in the coverage gap is continued to grow into the future. “By 2020, you'll pay no more than 25% for covered brand-name and generic drugs during the gap—the same percentage you pay from the time you meet the deductible (if your plan has one) until you reach the out-of-pocket spending limit (up to $4,950 in 2017; up to $5,000 in 2018).”

U.S Centers for Medicare & Medicaid Services

Bibliography

U.S Centers for Medicare & Medicaid Services. Costs in the coverage gap. 2017. https://www.medicare.gov/part-d/costs/coverage-gap/part-d-coverage-gap.html. 20 11 2017.