Medicare Ethical Dilemmas

: Insurance companies have the list of formularies that they agree to help cover but it is a tricky and a hassle to deal with. The patient must get a prescription of a similar drug first to make sure it works on them or even getting the doctor to prove that you need it. This is just to get coverage for an expensive drug. This can take weeks to do. It is a complicated list designed to give the patient the right drug for their conditions and that drug may not even be the first one that the doctor prescribes for them. It is a process to find out which one is right. When you fill a prescription of an approved drug of the formulary then you do not have to pay full price. Patients will have a copay through four different tiers. The first tier the patient pays a $20 copay on generic medications or a low cost medication, on the second tier, the patient pays a $40 copay for low cost brand names or a higher priced generic name drug. The third tier, the patient pays a $60 copay for brand name medication in which there is no generic, and the last and final tier which is number 4, the patient pays a $100 for the highest cost medication and/ or specialty drugs such as ones for chemotherapy. Some health care plan require the patient to pay full price for medication until they meet the deductible and then they can pay copays. Some formularies have coinsurance instead. The patient in these pays a percentage of

Background- The scenario in question involves a 77 year old widowed woman, Mrs. Zwick. Mrs. Zwick had a mild stroke, and was admitted and hospitalized as a inpatient for five days to ensure her condition was mitigated. After the five days, Mrs. Zwick was transferred to a skilled nursing facility for rehabilitation. However, Mrs. Zwick was uncomfortable, and tests revealed that she had manifested a hospital-acquired urinary tract infection. This infection was serious enough to require IV antibiotics and extended care for an addition forty days in the nursing facility. Upon discharge, Mrs. Zwick was prescribed several medications and had to get a walker. Due to her age and circumstances, Mrs. Zwick is enrolled in Medicare A, B and D she is not able to handle her bills and paperwork, so her daughter helps out. Mrs. Zwick and her daughter both were unaware that the urinary tract infection was considered a hospital-acquired condition all the nursing staff told them was that it had to be medicated.

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

The essential target of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) was to furnish seniors in the United States with moderate scope for their physician endorsed solutions through the new Medicare Part D professionally prescribed medication advantage. After the MMA was implemented—however before Part D was actualized—there was a disagreement about the cost of the program. In March 2004, the Medicare Chief Actuary affirmed before the House Ways and Means Committee of United States Congress that he was requested by the (Centers for Medicare and Medicaid Services) CMS Administrator to smother his assessments of the ten-year cost of the program, which were considerably more noteworthy than unique Congressional Budget

The pharmaceutical and biotech industry agreed to contribute billions of dollars to healthcare reform. Having agreed early in political negotiations to contribute any-where from an estimated $80 billion to $105 billion in fees, rebates, and discounts to help move the legislation forward (Nussbaum, 2010). By agreeing to support healthcare reform with their money and policies, they were able to avoid issues that had plaques their industries for years such as drug importation and the ability to negotiate drug prices for Medicare D. In return, the pharmaceuticals and biotech firms would agree to discount drugs purchased by Medicare beneficiaries, affected by the doughnut hole, of the Part D program by 50 percent (Spatz, 2010). Congress also proposed additional government subsidies to be added to the discounts that would further shrink the gap; beneficiaries will pay 25 percent copayment

The cost of health care has been at the forefront of politics for years. It is one of the most talked about topics not just in political venues but also country wide. Every American has an opinion on how our economy can be fixed and they are passionate about health care reform. The price of insurance alone causes many Americans to not have coverage. For those that can afford coverage, the struggle to pay co pays is immensely crippling their bank accounts. Of these burdens on Americans today, the most frightening fact lies in the cost of prescription medications.

Part D decreases their out of pocket expenses for prescription drugs for a lot of people. Therefore, a great decrease is recognized by patients with extremely high annual expenses for prescription medication. Though, Part D cost patients with low income more then what they previously paid to its adoption when state Medicaid programs covered them. The legislation that established Part D forbids Medicare from negotiating lower prices with drug manufacturers. As a result of an increase in costs of prescription medications frequently passed to the benefit recipients (Mathews, 2006). The legislation are groups that influenced the final outcome of Medicare Part D.

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

The pharmaceutical industry is one of the most powerful and greedy industries in our country, with a goal to make as large a profit as possible, at the expense of the sick.

In 2010, the Affordable Care Act created a $250 rebate if the Medicare beneficiary was in the coverage gap. It also expanded coverage to the discounts given on brand name prescriptions. With reforms and improvement comes disadvantage to others. Beneficiaries and patients will be able to start saving more money, but it comes with a decline for the drug providers. According to Health Capital Consultants, “over ten years, closing the coverage gap may ultimately cost approximately $32 billion” and the pharmaceutical industry will be forced to take on most of this burden. These companies are paying for the flexibility they’re been given by MMA. They can “set their premiums, design their own formularies and are free to use cost management tools” and Medicare will reimburse plans for a “share of their drug costs.” (Guterman & Huynh ,

Managed Care is a system of health care in which patients agree to visit only certain doctor and hospitals, and in which the cost of treatment is monitored by a managing company. David, a clinical supervisor of one pad was responsible for the clinical supervision of eight clinical case managers. On typically day, he receives around 40 phone messages about clients that are in need of his services. His job is to field calls from mental health providers seeking authorization to provide treatment for clients. There are those who believe that managed care is simply another example of corporate America discovering a means to increase profits for shareholders of insurance companies, at the expense of individuals seeking mental health treatment. (pg.

The Medicare Drug Price Negotiation Act (S. 2011) would amend Title XVIII of the Social Security Act to allow for the negotiation of drug prices on behalf of Medicare beneficiaries for those medications covered under Medicare Part D. The policy would be enacted at the federal level, and the policy tool used to do so would be federal funding. Under this bill, the Secretary of the Department of Health and Human Services (DHHS) would be given the power to negotiate drug prices as well as establish and apply a specific formulary for Medicare-covered prescription drugs. Past rhetoric had implied that Donald Trump would have supported this bill; he condemned the role of pharmaceutical companies creating high drug prices as

In addition, the article highlighted the issue of litigation and policy context under the Employee Retirement Income Security Act’s (ERISA’s) preemption provision. It stated that “when a law or legal action involves the administration of plan benefits, such as a state law mandating certain benefits or a patient’s challenge to the denial of a plan benefit, ERISA preemption is triggered” (Jacobson, 1999). Therefore, the states block the litigation against the managed care organizations. Lastly, the courts and public policy have been a challenge of the implementation of cost containment initiatives. Some prominent commentators have been arguing for years that health care delivery should be guided by market principles as determined through contractual

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

Five different levels of classification for approved prescription medicines are included in the formulary; drugs in lower tiers cost the patient less than those listed in higher brackets. Medicare plans and patients copay for drugs, if a pharmacist decides that a drug listed in a higher bracket is needed over one listed in the lower price range, the patient can file an exception with the plan, as reported by medicare.gov.