Financing and Health Care Reform From A Pharmacists Perspective

I'd like to offer perspective as a health care provider who is looking at financials in the trenches. I am a pharmacist practicing in a specialty pharmacy supporting children's health care. Administration of the benefits currently provided by the government is time-consuming and overwhelming at times.

In Wisconsin, rebates are given to the state from companies who are currently "on contract" or on formulary. The formulary, or list of medications that are covered, changes monthly. In April, Wisconsin Medicaid decided that two generic medications used to treat gastroesophegal reflux disease (GERD) would no longer be covered, but a brand name medication would be. To be proactive and provide better patient care, we contacted each physician prescribing the two older drugs. The physicians had to decide to switch to Aciphex (which is not FDA approved for use in children), or put through what is called "prior authorization" (PA) paperwork to substantiate why that patient required the older therapy. Neither the physicians nor the pharmacists are compensated for this, and the patients who need medication wait. If time is money, then this is a huge indirect cost of health care. When we're doing this, we're not doing our "real jobs".

Why is the state switching patients from generic medications they are stable on to a more expensive brand name? Waste. Formularies switch month to month which is waste resulting in poor patient care. Why is the state requiring the use of a mediation in children which is not FDA approved for use in children? Stupidity or greed (don't forget about that rebate check the state is getting).

The government will not only provide the means for health care, but will be directing health care as it is on a state level now. I don't think we as a society have really considered how this "Obama Care" will be implemented. Physicians will be overwhelmed with these types of requests, and even the most dedicated health care professional will have to lower their standards of care. The first reform we need is the elimination of waste, corruption, and poor judgment in the systems currently in place. Take this one example on this one day, multiply it by 365 days a year and 50 states. Hey, this is only your visit to the pharmacy too! Hope you all have lots of free time to wait around for your affordable health care. I am honestly scared.

Anonymous RPh

Education and Health Care

I’m not sure where to start because this is a very important topic and one that is a big issue right now in health care. I think it is good that there is discussion in classes on this. I personally have not been offered or required to take a U.S. Health Care class so I feel that I have a lot to learn, but I do have opinions from my own experiences. It would have been nice to learn more about the health care system before having to enter it completely. I feel that education is a very important part of life and you should always be open to learning anything available, especially about something as important as health care.
I am a senior at Marquette University in the Physical Therapy department. I see injuries on a regular basis, but they usually happen on the field and then I don’t get to see the experience they have with the health care system afterwards. I have had my own experiences and my family and I are still paying for those. We are in the middle class and when there was an accident in the family, the last thing I wanted to worry about was how my family was going to hold up afterwards. Consequently, I worried about it anyways.
I know the health care reform is changing right now and there will be improvements in the amount of coverage, but I agree with the idea of universal coverage. I don’t think anyone should be denied. I feel that it becomes a vicious cycle when people can’t afford care, so they don’t get regular check ups, and then they end up getting sicker because they couldn’t afford it in the first place. Or even find themselves in even greater debt after an incident. I don’t see who is benefitting in the system now, except for the specialty physicians. I know when people bring up raising taxes that others go haywire, but I would actually be up for increasing taxes to a point so everyone would be covered under health care.
I’m not sure if I agree with the point to strengthen the Medicaid and Medicare programs entirely. I do think that there should be more or stronger government systems, so maybe that reform could work, but it could also be a good idea to create a new one. Even though this might be a difficult process, sometimes complex situations require a complex solution.

Financial Stress and Cancer

As a breast cancer survivor, my thoughts on the health care system may be unique compared to those that have not gone through cancer. To give a background, I have an HMO for insurance, which I am actually very lucky to have. I have 100% coverage with a $20 co-pay for each doctor visit. Our premium is $600 a month and this is all through my husbands work. At one point throughout my chemotherapy treatments, I ran out of checks to pay my co-pay, so I asked to be billed. Because of being on an HMO, I have never seen a bill so I was shocked when the bill came to my house and a charge for one chemotherapy treatment was $16000! I had no clue this was how expensive a treatment was!

The Neulesta injection was another shocker to me. This injection is given after each chemo treatment to keep my WBC count up. This injection alone cost $12000 per shot! I had 8 chemo treatments, that’s 8 shots, or $96,000, not including treatment. Even now that I am finished with treatment, I have to take Aromasin. After women go through menopause, they take you off tamoxafen and put you on aromasin, which is a fairly new drug, and because of it being a fairly new drug, it doesn’t come in generic form. This leads to a high cost, even with my HMO. My co-pay is $75 per month. If I did not have insurance, this drug would cost $350 per month. They are now saying that they want women to take it for the rest of their life. LOTS OF MONEY. I am just lucky that I had an insurance company that worked with me so I did not have to pay these bills and it does show that there are good insurance companies out there.

However, a friend of mine just finished radiation therapy treatment and she doesn’t have an HMO. Her insurance is a %80-20%, and she has a yearly deductible. This lead to a lot of out of pocket expenses. During her treatment, she wouldn’t be feeling well and would still come into work because she had too many medical bills to pay and not enough sick time. The insurance company was badgering her for money even after she would pay the minimum payment. I feel this is just terrible! At least let her get through treatment!

She recently finished her 2nd round of radiation and for some reason her insurance is denying coverage. She now has a $27,000 bill because the insurance claimed her treatment to be experimental. Since I work with insurance, I know how it works and the various medical codes used. I am currently helping her to draw up letters to her insurance to get covered because I feel that maybe they need to re-think or re-code or something because she is being denied coverage, even with documents from her doctors to back her up. She has now hired an attorney to try and get this covered as well.

In the meantime, they are trying to send her to collection. This is a big financial burden which is causing a lot of stress. She is trying to recover from treatment and doesn’t need this added stress on her life over something like money. When you see some of these prices, this makes me wonder what happens to someone who doesn’t have insurance at all. They would probably get denied treatment because they don’t have enough money. I feel that the financial issues with the healthcare system is one of the first things that needs to be addressed when trying to improve American health care. I also believe that everyone has the right to coverage, and good coverage, along with payments that are affordable and livable. Overall, health and quality of life are the most important things and the health system needs to remember that.

Financing in Radiation Oncology

Health care financing in radiation oncology is a multifaceted issue. On one hand the field itself is constantly evolving improving that way that we treat cancer. It is important for these changes to occur and the patients deserve the very best methods of treatment for their cancer. However these changes tend to bring with them, greater costs not only to the facility, but eventually the patient. It is important that physicians use technology with a grain of salt to treat their patients. The advanced technologies should never be used only to generate revenue, they should only be utilized if deemed necessary for the control of a patient's cancer. Many times, more simple treatment methods are just as effective, even if there are more advanced methods available in a department. I recall hearing administrators talking about how we have this technology now, and we need to utilize it as much as possible to pay for it. I don't agree with this thinking if it means requiring patients to pay more for their treatments just so our technology meets a certain level revenue generation.

The other issue of concern is insurance coverage for cancer patients. It was heart-wrenching for me to watch patients struggle to pay for their co-pays, medications, and sometimes transportation and lodging, all while fighting for their lives. It is just not right that patients have to decide between healthy food which is just as important in healing and getting treatment. In my opinion, patients should just have to focus on healing, not the other issues. The reasons why they had to worry about them were: they lost insurance coverage because they couldn't work, their insurance was not adequate to cover their treatment, or lastly they lost their income because of their disease and did not have short term disability insurance. It seems that a good government program could see to that patients are able to receive the care that they need for treatment of the cancer without having to lose everything in the process, or go into severe debt.

Part of the new health care reform focuses on prevention and treatment of chronic disease. For patients that battle their cancer for months and years, this is a chronic disease and one that could greatly benefit from government assistance. At the same time, there needs to be more health care available to those that are under-served so that they can have their cancers prevented or detected in earlier stages. The trend currently is that those of low socioeconomic status have their cancer diagnosed at much later stages when they are advanced or metastatic, because they did not have adequate health care to detect it when it was in its curable stages. So basically people lose their lives to advanced cancer that could have been cured if they would have been able to have the necessary medical care earlier in the process.

As you can see there are many issues in radiation oncology regarding the financing of this type of health care, and many of the solutions start with physicians and administrators acting ethically to treat their patients.

Reform Proposoal #2

Medicare is the federal health insurance program that covers most people age 65 or older and some young people who are disabled or have end-stage renal disease are also eligible. Medicaid is a federal government program designed to ensure that the poor and children and pregnant women living under poverty level receive quality health care.

Our second health care reform proposal is to strengthen these current government programs because we have good programs that just need to be built up, not completely torn down.

If policymakers want to improve access to needed health care services then significant changes to Medicare need to be made. As the ratio of retirees grows in relation to the working age population, it will be more difficult to fund medical care for seniors. Strengthening Medicare will require modifications in several areas. Some ideas to get the best value from our health care include placing a priority on preventative care and chronic care management and making health care delivery more efficient by developing clinical practice guidelines that promote service utilization. To improve health care decision making it will help to support funding for quality research that will improve health care value and design systems that provide applicable, timely and actionable information that will help physicians provide the best possible care. Patients should also have support and incentives. This can be accomplished by reforming beneficiary cost-sharing so that patients have a single premium and deductible for all Medicare services. Also, providing subsidies to help low income beneficiaries meet their cost sharing duties and looking into facilitating more efficient and meaningful approaches to cost-sharing will provide incentive to patients.

The Centers for Medicare and Medicaid Services (CMS) oversees the program at the federal level, while the states deal with the day to day business. CMS and Congress should enhance oversight of the Medicaid program. Congress should consider requiring increased attention to fiscal accountability by requiring Health and Human Services to improve the demonstration review process.

Some people believe that the financing issue in our health care system is not as important as others because they consider quality to be the most important of the three legs in the three legged stool of health care; cost, quality and access. They argue that the type of care people receive is the main thing that should be in concern. This would allow people to receive better service and treatments. Although this is an important point, we disagree because nobody can even go in for care if they can’t afford it. People are denied service because they do not have insurance and people are living without any health care because they do not have the means to pay. If more people could afford care, the U.S. could start the transition from acute care to preventative medicine.

Instead of bashing the current system we have now, we need to work on a plan that will fix it and make it more beneficial for more people. Strengthening the current government programs will help to make insurance and health care more affordable for Americans.

Bridget Morgan

1. Shi L, Singh D. Delivering Health Care in America: A Systems Approach. Sudbury, Massachusetts: Jones and Bartlett Publishers; 2008.
2. Dawn, Ralph. Medical Eligibility/Coverage. Topic Collection: Medicare and Medicaid. U.S. Government Accountability Office. December 15, 2009. http://www.gao.gov/docsearch/featured/medicaid_eligibility.html. Accessed March 10, 2010.
3. Gleckman, H. Long-Term Financing Reform: Lessons from the U.S. and Abroad. The Commonwealth Fund. February 17, 2010. http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2010/Feb/Long-Term-Care-Financing-Reform-Lessons-from-the-US-and-Abroad.aspx. Accessed March 8, 2010.
4. Strategies to Improve Medicare. American Medical Association. April 2008. http://www.ama-assn.org/ama1/pub/upload/mm/399/nac_strategies.pdf. Accessed March 10, 2010.
5. Kanof, M. Medicaid Program. U.S. Government Accountability Office. September 9, 2009. http://www.gao.gov/highrisk/risks/insurance/medicaid_program.php#needs. Accessed March 10, 2009.

Reform Proposal #1

Financing is the key when it comes to health care reform. With approximately 41 million people uninsured, it puts financial strain on the hospital and the patients. With the uninsured not seeking primary care, they are receiving much more expensive care in the emergency room. In order to lower overall cost, the option to having affordable health insurance needs to be available to all.

We propose that the government should more closely regulate prices of procedures and hospital visits, making it less expensive for all. Insurance companies could then cut cost of premiums and insurance plans. Currently, the system has no set prices for standard procedures and the prices vary throughout the entire country. This will allow competition between insurance companies.

Insurance should be available to all, however we feel that the American people should have a choice whether they want to pay for insurance or not. Some people may feel that they still can not afford insurance but do not qualify for government programs; in this case, the government will provide tax breaks that are comparable to the cost of insurance one could get through an employer. That way, those who are not insured still receive some help for medical needs. The government should also provide a type of temporary insurance for those who are between jobs. It will allow those who are between jobs to not worry about health needs while they are switching jobs.

If there is more affordable coverage, this will allow more people to become insured. If there are more people insured, this will increase the number of people using primary care. When people use primary care, they are more likely to practice preventive care rather than waiting until a condition gets very serious and expensive to treat. Overall, quality of life would increase. With more people covered, hospitals can decrease the amount of cost shifting that is going on, making health care all around more affordable, even for those who could afford insurance in the first place.

Financing is the most important part of the health care system. If health care is too expensive, no one would be able to access health care. However, if health care had no money coming into the system, it is a good guess the care received would be less then satisfactory. There needs to be some balance between access, cost and quality. Financing is therefore the most crucial part of the health care system and must be closely monitored to make sure the system is working efficiently.

Mindy Opelt

1. Shi L, Singh D. Delivering Health Care in America: A Systems Approach. Sudbury, Massachusetts: Jones and Bartlett Publishers; 2008.
2. Health Care Crisis. PBS. Available at: http://www.pbs.org/healthcarecrisis/ uninsured.html. Accessed February 28, 2010.
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4. Antos, J.PH.D. Financing Health Care Reform. 2009. Available at: http://www.aei.org/docLib/Antos.pdf. Accessed: February 28, 2010.
5. Quick Facts on the Uninsured. Cover the Uninsured. 2009. Available at: http://covertheuninsured.org/content/quick-facts-uninsured. Accessed: February 28, 2010.

Overview/History

Over the past several decades, the cost of health care in the U.S. has dramatically increased. Financing health care is done by three major contributors; the government, private insurance companies and the consumers. Since the costs of health care in the U.S. has increased so dramatically, consumers are struggling to pay without financial help. That being said, it is no wonder that both the government and private insurance companies have stepped in to pay a large chunk of health care costs for the consumer.

Financing health care in the U.S. is an extremely complicated topic because of the many different financers we use. There are 3 major characteristics that describe how the U.S. finances health care. The first topic of interest is private insurance. Much of U.S. health care financing comes from private insurance companies. They will cover a certain percentage of the total health care bill. Most people receive private insurance from their employers. It can be purchased individually, although it may be more expensive. The next example of financing in the U.S. is government based. Government programs are directed towards people who are older, disabled, low-income, or those that have government based jobs such as those in the military. The government is a major financial contributor for health care in the U.S. with programs such as Medicaid, Medicare, Workers Compensation, and other similar programs. Lastly, the next type of financing for health care in the U.S. is those who pay for health care costs on their own. Those that choose this type of plan are generally in financial trouble and cannot afford private insurance. They usually do not qualify for government programs. For those who are financially well off and choose to not invest in private insurance most likely choose this because they are healthy and feel they will save money this way.

The United States spends almost two trillion dollars a year in health care costs, or about 16% of the total GDP. This ends up being about seven thousand dollars per person a year spent on health care costs. Although that is a rough estimate of what each American spends, it is safe to assume that some are spending much less than that, while others are spending much more. For those Americans spending more, a cost like this could be debilitating to a low-income family. It is very important to have public or private sectors financing health care. A great example is when a family member needs to go to the hospital for a kidney stone removal procedure via supersonic waves (no surgery). The total cost charged by the hospital would be twenty-five thousand dollars for a four hour hospital visit.

Without financial help from the government or a private insurance company, it is safe to say that no family would be able to afford such steep costs. Both private and public insurance programs greatly increase the amount of people who have access to health care in this country. With roughly forty-five million+ Americans without insurance coverage, the U.S. still has a lot of work to do.

It is also important to state that without appropriate financing, hospitals would end up in serious financial trouble. It would be debilitating to the health care system as well. This has a direct effect on the quality of health care consumers would receive. Without proper funding, hospitals would be unable to support a full staff or provide up-to-date technology needed for diagnostic and treatment purposes.

The topic of financing health care is the most important topic in healthcare because without financing, health care would be almost non-existent. It is important to realize that financing health care has lead to major advances in the medical community and should be the first thing to consider when reforming health care in the United States. It also may be the hardest part to change. One may argue that other aspects of health care, such as technology, is the most important topic but without financing health care, hospitals would not have the money they need to bring in new patients, have up-to-date technology and the amount of staff they have now. Everyone needs to focus on the financing aspect of health care in order for reform to move forward.

Kayla Engel

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4. Shi L, Singh D. Delivering Health Care in America: A Systems Approach. Sudbury, Massachusetts: Jones and Bartlett Publishers; 2008.
5. A Short History of Health Care. Slate Magazine. 2007. Available at: http://www.slate.com/id/2161736/. Accessed February 19, 2010.