Speaking Notes
PADM 5791
February 10, 2010
Dr. Neubauer
WHERE WE ARE
We are in Chapter 4 now on Medicaid.
I plan to distribute the midterm
exam on the 17 of February to be returned completed on Feb. 24.
Chapter 4 -- Medicare
The quotation of page 166 is pretty
heavy. If Medicaid is Pac man and
Medicare is becoming a bureaucratic leviathan, where should be go?
"Leviathan" refers to a
sea monster and one of the seven princes of hell."
http://en.wikipedia.org/wiki/Leviathan
This reads to me a bit like a course
titled, "Growing Old in American 101."
Concluding sentence, "We live
in a brave and scary new world."
Medicare has been and is the first
edition of national health insurance.
Its problems and failures both highlight the need for national health
insurance and the difficulty in getting there, both politically and from a
practical perspective.
Medicare began with intent to
provide insurance coverage for a specific population -- US citizens 65 and
older. The base has been expanded to
include citizens with disabilities and those eligible of SSI.
Medicare was not designed to be a
"welfare" program. But by its
expansion it may be becoming more nearly one.
Medicare was passed in the 1960s
with BIPARTISAN SUPPORT.
The basic problem was that our
medical insurance system is based upon employment and some employers do not
continue to provide coverage for people when they retire. (Plus, employment is not what it used to be.)
In 1963 only about 54% of the
elderly had hospital insurance. This
creates problems not only for patients but for physicians and hospitals.
Medicare has FOUR PARTS.
Part A -- hospital insurance plus
some hospice and home health services
Part B -- voluntary part including
some physician and outpatient services (a bargain for those who can afford it) SMI or supplementary insurance program.
Part C -- managed care (Medicare+Choice).
option to enroll in managed care programs including HMO's (Health
Maintenance Organization)
Part D -- MMA. includes some drug coverages.
http://en.wikipedia.org/wiki/Medicare_Part_D
MMA rerfers
to Medicare Modernization Act of 2003 which went
into effect in 2006. (following
information is from the Wikipedia entry.)
The average monthly premium for stand-alone Part D plans
(PDPs) with basic benefits that do not offer gap
coverage are $30.14; the average monthly premium for plans that do offer some
gap coverage are average $63.29. By the
design of the program, the federal government is not permitted to negotiate
prices of drugs with the drug companies, as federal agencies do in other
programs. The Veterans Administration, which is allowed
to negotiate drug prices and establish a formulary, pays 58% less for drugs, on
average, than Medicare Part D. For example, Medicare pays $785 for a year's
supply of Lipitor (atorvastatin),
while the VA pays $520. Medicare pays $1,485 for Zocor,
while the VA pays $127.
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Medicare is financed by payroll
taxes, deductibles and co-payments.
Most physicians accept Medicare (and
the rates of reimbursement). If your
physician does not, you pay him/her out-of-pocket and you get reimbursed part
of the money from the government.
Most elderly citizens have some
medical insurance in addition to Medicare.
These are sometimes called Medigap
policies. Some employers provide some
medical care insurance to their retired former employees.
Under the HMO plans there is an
incentive for the HMO's to "cherry pick" healthier patients. I think they get PROSPECTIVE PAYMENTS for
meeting the medical care needs of their patients, which gives then an incentive
to hold costs down. There are PEER
REVIEW ORGANIZATIONS (PRO's) that monitor quality of
care. If an HMO does not do well they
stand to lose their ability to participate in Medicare. Generally, patient satisfaction with HMO's
seems to be pretty good.
Medicare is not able to provide
catastrophic coverage or to pay the very high costs of long term care. The "donut holes" are the result of
this reality. Medicaid "kicks
in" when people/families that once had substantial wealth spend out what
they have.