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Health and Human Services
- Cabinet section
- Medicare, Medicaid and FDA
- 35% of expenditures
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FDA
- drug approval
- otc and entry of generic drugs into market
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1906
Original food and drugs act passed
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1938
- federal food, drug and cosmetic act
- elixir sulfanilamide
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1962
- kefauver-harris drug amendments passed to ensure safety and efficacy
- thalidomide
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1995
- FDA declares cigarettes to be drug delivery devices
- restrictions of sale and marketing
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2009
regulation of tobacco
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Senate Funding commities
- Health, Education, Labor and pensions committee
- Finance committee
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House funding authorizing comittees
- house committee on energy and commerce
- house ways and means committee
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HRSA
- analysis of health professional needs
- 340B program => funding for teaching hospitals
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State roll in health policy
- regulation: boards, inspections
- Purchaser
- Provider
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State roll as healthcare regulators
- professional licensing
- health facility licensing
- insurance company and managed care organization regulation
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State role as health care provider
- Facilities for developmentally disabled
- State operated nursing homes and veteran's homes
- prisons
- public and population health
- medical schools and teaching hospitals
- programs for targeted populations
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Public Health Service provided by the state
- Disease surveillance
- statistics and record keeping
- operation of pathology labs
- injury prevention and public safety
- protection from environmental hazards
- medical research
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Our Health care system is a mixture of
- public segments
- third party payers
- private entities
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Medicare
solely financed by the US Federal Government
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Medicaid
Jointly financed by the federal and state governments
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Government sponsored health insurance
Pt. doesn't pay to enroll
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Types of prescription drug plans
- ~53 plans in MO
- stand alone rx drug plans
- medicare advantage plans < 10 in each state, more common in urban areas
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Pharmacy Networks
the pharmacies that can fill rx drugs in your medicare part D plan
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Part D Coverage
- formulary restrictions
- one aspect of each class is covered, but not all drugs in the class
- six classes of drugs must be covered by all plans
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Part D Eligibility
- 7 month window around age 65 (initial enrollment period)
- those with limited income may be automatically signed up
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Drugs not covered by Part D
- OTC
- Barbiturates
- Benzodiazepines
- Vitamins
- Weight loss drugs
- Cosmetic Drugs
- ED drugs
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Medicare Part D Benefit
- Administered by private regional plans
- Plans are medicare advantage or stand alone plans
- At least 2 plans per region
- 50+ plans in MO
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Formulary Exceptions
- Patient can petition with documentation from their physician that a non-covered drug is needed.
- Pt. can request drug change teir
- A response is expected within 72 hours.
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Deductible for Part D
Plan pays 3/4 for the first year
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Donut Hole
- pt pays 100%
- phasing out 10/10 pt receives $250
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Ways to reduce healthcare costs at hospitals and specialists
- Improved in-patient care process
- use of lower cost treatments
- reduction in adverse events
- reduction in preventable readmissions
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ways to reduce healthcare costs at primary care practices
- improved prevention and early diagnosis
- improved practice efficiency
- reduction in unnecessary tests and referrals
- reduciton in preventable ER visits and admissions
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Ways to reduce health care costs at all providers
- improved management of complex patients
- use of lower cost settings and providers
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Medicare Part A
- Hospital Insurance
- Inpatient Hospital, Skilled Nursing Facillities, Home Care
- Automatically eligible at age 65
- No premiums
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Medicare Part B
- Supplemental Medical Insurance
- Office Visits
- outpatient services
- drugs administered at an outpatient clinic
- Must sign up
- premiums vary per month and increase each year
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Medicare Part C (Medicare Advantage)
- Sign up and it is payed for with taxes and premiums
- Part A, B and D provided through a privet HMO
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Part D
- Rx drug insurance
- Premiums vary depending on which plan you choose
- must enroll
- penalty of 1% of premium added each year that you didn't enroll after age 65
- formulary may change at any time
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