Effects of the Drug Renvela: Case Studies

Many people are seriously ill when they seek treatment because they lacked enough money in their insurance for treatment (Bush, 2015). Although people have reported general satisfaction with their health plans under PPACA, a Kaiser Family Foundation (KFF) survey has revealed that affordability is a concern for those who buy their own health insurance. 46% of those with both ACA-compliant and noncompliant plans reported it was “very” or “somewhat” difficult for them to afford their monthly health insurance premium (Medical Economics, 2015). Cost of care has been a longstanding barrier to care for minority groups. The survey did not find an improvement in Blacks and Asians skipping care due to cost concerns. (Pallarito, 2015).

Medicare Parts A and B. There is a monthly premium for this coverage (Medicare 2013 costs at

Specific coverage and benefit details vary from state to state (Raffel, 224). This is intended to help people with high medical costs that are not old enough for Medicare.

Medicare part D is the prescription drug plan. Each plan has its own list of covered drugs (called a formulary). Many Medicare drug plans place drugs into different tiers on their formularies. Drugs in each tier have a different cost. For example, a drug in a lower tier will generally cost less than a drug in a higher tier. In some cases, if the drug is on a higher tier and the patient 's prescriber (the patient 's doctor or other health care provider who is legally allowed to write prescriptions) thinks the patient needs that drug instead of a comparable drug on a lower tier, the prescriber can ask the patients plan for an allowance to get a lower copayment. In the case of Mrs. Zwick Part D will cover the prescription drugs that she needs that are not covered by Medicare Part A and Part B unless those medications are on the unapproved list. What the patient will be responsible for paying

Medicare Part D Drug Plan was created by Congress in 2003 to aid the elderly, disabled, and sick persons in affording their medication. Coverage for the drug plan went into affect January 1, 2006. This plan was called the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA) (Cassel, 2005). The final bill that passed, was influenced by drug-company and health insurance lobbyists and focused mainly on the needs of those industries instead of the seniors it was meant to serve (Slaughter, 2006). These plans are operated by insurance companies and some private companies that have been approved by Medicare. Part D is optional only if a person carries health insurance that includes prescription coverage. If at retirement

Medical costs are getting too expensive. Ever fought with your insurance providers because they refused to pay for care, or struggle to find an “in-network” provider? I know a woman whose name I will change for her privacy and the struggles she is going through are a perfect example of an issue many people face when dealing with insurance; Nancy’s (name changed for privacy) story is a perfect example of how our healthcare system is no longer working for the people. Nancy is this woman whose husband recently passed away. Nancy used to work for county and county workers cannot receive social security; and Nancy is too

pays 86% of the cost of generic drugs during the coverage gap. The patient may get a 50%

He is relieved to have access to the Medicare drug addition program. Although he feels strongly that the large pharmaceutical conglomerates of the world need to decrease the price of drugs. As a pharmaceutical company employee I informed him of the many programs available to help with the pharmaceutical cost of drugs. I do agree, the pharmaceutical companies need to continue working with those individuals in government, insurance companies and health care to provide access to affordable and novel compounds to all who need them. There are pharmacy and retailer prescription drug discount programs available. Discount drug cards are offered through chain pharmacies for a small monthly premium and provide discounts on a number of services, including prescription drugs. Individuals with a Part D plan may use a discount card, but the two drug programs operate independently of one another. Drug card discounts cannot be applied to Part

Fifty years ago, Lyndon B. Johnson signed the Medicare program into law. “It has been a reliable guarantor of the health and welfare of older and disabled Americans by paying their medical bills, ensuring their access to needed health care services, and protecting them from potentially crushing health expenses.” (Hamel, Blumenthal, Davis, & Guterman, 2015, p. 479). With the encouragement of George W. Bush, congress passed the Medicare Modernization Act of 2003 (MMA). The MMA extended Medicare to include prescription-drug coverage, known as Medicare Part D. In 2013, Medicare covered the health care expenses for 52.3 million Americans, costing $583 billon. Originally, Medicare had difficulty controlling costs; physicians and hospitals were

The passage of the Medicare Drug Price Negotiation Act will also inadvertently increase access to many types of medications for individuals who qualify for Medicare Part D. There is a clause within the bill that would establish rebates to be paid by pharmaceutical companies for low-income beneficiaries. These rebates, in addition to lowered costs, would considerably lessen the financial burden placed on low-income beneficiaries. This will allow more individuals greater access to expensive medications. As an example, each year, financial reasons hinder about 16% of diabetic Part D beneficiaries from filling at least one of their prescriptions (Williams, Steers, Ettner, Mangione, & Duru, 2013). This increase in access will help mitigate the occurrence of cost-related nonadherence to prescription medications, and other such consequences

Under the existing federal Medicaid pharmacy benefit program, fee-for-service reimbursement rates for prescription drugs are based on the actual invoice cost of prescription drugs plus a reasonable professional dispensing fee. Any federal reforms to Medicaid which would allow states to set Medicaid pharmacy reimbursement rates below actual drug acquisition costs could seriously jeopardize Medicaid patient access to Medicaid drugs. Whether in a Medicaid managed care or fee-for-service setting, a Medicaid program that reimburses below actual drug costs raises a barrier that may limit or eliminate access points for patients to utilize their Medicaid drug benefits. Even with a cost-based drug reimbursement floor, Medicaid programs can fully avoid patient access barriers only through the addition of adequate dispensing fees that are more reflective of the cost to provide healthcare services in the

Mrs. Jones, like many older adults, is on a fixed income, has Medicare for health coverage, but lacks prescription drug coverage. She was recently prescribed a new medication by her physician, which she cannot afford. As Mrs. Jones nurse, it is my responsibility to advocate for her by providing education and sharing information on the multiple different avenues available to decrease the cost of the medication prescribed. I will identify three strategies in which I can help Mrs. Jones afford her medication. First, I will provide education on her insurance plan and explain Medicare Drug Plans and their enrollment process. Secondly, I will identify a financial assistance program which she might qualify for. Finally, I will identify different ways to lower the cost of the medication such as coupons, drug discount cards, switching to a generic medication, and store programs ("Prescription Drug," 2014). All of these options are a solution to Mrs. Jones problem. In the meantime, it may be beneficial to obtain free samples from the physician 's office if possible, but this only makes sense if there is a strong likelihood that she will eventually be able to afford the new medication.

Since the patient resides in California, I’ll focus on California’s Medicaid Program.  California’s Medicaid program is known as Medi-Cal. In 2015, there were about 12 million Medi-Cal members.  Services that Medi-Cal provides for eligible patients are doctor’s visits, diagnostic testing, emergency services, surgery, and many more. As stated in the Covered California website, people who are eligible for Medi-Cal are low-income adults, families with children, seniors 65 and older, people with disabilities, blind, pregnant women and individuals under 21. The patient is also eligible for Medi-Cal if he is a part of the following programs such as the Supplemental Security Income/State Supplemental Program (SSI/SSP), and the Medically Needy

As exemplified by the case, CTCA generally targeted patients with PPO insurance and only cares for a limited number of Medicare insured patients due to Medicare’s low reimbursement rates and travel limitations (CITE Case). Therefore, the segment of the market made up of lower socioeconomic status individuals is not an attractive segmentation to target as there is a greater likelihood of such individuals being insured by Medicare. To further support this notion, the case states that even Medicare patients who could afford to pay for CTCA treatment using their own savings were legally barred from doing so (CITE case).

Unnecessary services are provided far too often because there is little coordination across sites or among providers, yet care management, cross disciplinary care, and preventive care are often uncovered or poorly reimbursed. Notably, 45% of the U.S. population have chronic conditions requiring care management. Of this population, 60 million, or roughly half of those with chronic conditions, have multiple conditions. Current care delivery systems are not designed to support the care of these complex patients, which requires multiple providers and services.