advocacy: access to care
TRANSCRIPT
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ADVOCACY MORNING REPORTSeptember 16, 2011
WENDY Hobson-Rohrer, MD MSPH
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1ST CASE
3 year old comes into your continuity clinic for avisit. Her BMI is less than the 5% and her weightis also below the 5%.
You would like to give her increased calories andare considering a supplement.
She is uninsured.
What questions will you ask to assess whichprograms she can use?
What are the potential programs that she canaccess?
What supplement will you do?
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WIC WOMENSINFANTSANDCHILDRENSPROGRAM
US Citizens
Covers children less than 5 years age
Covers children who live in families under the
poverty line Supplemental program does not cover all food
If a child is G-Tube dependent and 100% of thefeeds are via G-Tube, then insurance pays for the
formula, not WIC
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WIC GUIDLINES
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INCREASINGCALORIESFORLOWCOST
Whole milk 17kcal/oz
Carnation instant breakfast with whole milk 30kcal/oz
Pediasure or other equivalent formula 30 kcal/oz Pediasure $9.97 for 6 bottles
Equate (Wal-Mart) - $5.97-6.97 for 6 bottles
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REASONSTO UNDERSTANDINSURANCE
Refer appropriately
Empathy
Impacts medical care
Personalize care Credibility
Advocacy
Get paid
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VOICESFROMTHE FOCUS GROUPS-COMMUNITY
Problems in getting medical care?
Low income people cant afford it.
My doctor didnt know whats covered.
It helps if the doctor knows what yourfinancial limits are.
Doctors dont know the price.
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INSURANCE ATLAS
Decision Tree
Start at top center box
Clear boxes contain criteria
Yes/No until reach shaded box
Shaded box = Insurance/Medical Program
If no arrow, then no option
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DEFINITIONS
US Citizen= birth in US
Lawful Permanent Resident= Green Card
Poor= below poverty level
Low Income= financial need, depends
Renal Failure= renal transplant OR dialysis
Disabled= Eligibility criteria specified by SSI
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SOURCE: Federal Register, Vol. 76, No. 13, January 20, 2011, pp. 3637-3638
2011 HHS Poverty Guidelines
Personsin Family
48 ContiguousStates and D.C. Alaska Hawaii
1 $10,890 $13,600 $12,540
2 14,710 18,380 16,930
3 18,530 23,160 21,320
4 22,350 27,940 25,7105 26,170 32,720 30,100
6 29,990 37,500 34,490
7 33,810 42,280 38,880
8 37,630 47,060 43,270
For eachadditional
person, add3,820 4,780 4,390
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Citizen orLawful Permanent Resident
Poor & Either
1) Pregnant OR2) Life Threatening Disease
Renal Failure
Poor
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INSURANCE OVERVIEW
State & Federal Programs
Local Programs
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MEDICARE VS. MEDICAID
Federal $$
Federally administered
National eligibility criteria
Apply at Social SecurityOffice Medicare, Disability, Social
Security
Federal & State $$
State administered
State-determined eligibilitycriteria
Apply at Division of
Workforce Services offices Medicaid, Emergency
Medicaid, Baby Your Baby,CHIP, PCN, Medicareassistance programs
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MEDICARE VS. MEDICAID
Citizen/Resident
&
Social SecurityQualifications
&
> 65 years old
Disabled x 2 yrs Renal Failure
Citizen/Resident
&
Poor
&
65
Disabled or blind
Pregnant Parent/caretaker of a child
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MEDICARE VS. MEDICAID
Covers: Minimal health maintenance Symptomatic care Some medications
YES:pap, mammo,prostate CA screen,colon CA screen,flu & pneumovax
NO: vaccines Many complex options
State Health InsuranceAssistance Program
Covers: Health maintenance Symptomatic care Medications
Many different plans
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BABY YOUR VS. EMERGENCYBABY MEDICAID
Presumptive EligibilityProgram
Short-term (45 d) immediatecoverage While apply for Medicaid
One BYB card/pregnancy
Covers: Prenatal
General medical care
Medications
Criteria US Citizen/Resident
+ Pregnancy test
Income limits
Medicaid & other sites
Emergency Services for Non-Citizens
Emergency services only Pregnancy (only L&D costs)
Life-threatening disease
Poor non-citizens &
non-residents of US
(including illegal aliens)
NO risk to be deported
Medicaid offices
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CHIP VS. PCN
Childrens Health
Insurance Program
State administered Criteria
US Citizen/Resident Child Low-income Not qualify for Medicaid
Covers
Health maintenance General medical care Medications
Open-enrollment Now should be open
DWS offices
Primary Care Network
State administered Replaced UMAP Criteria
US citizen/resident 19-64 yo Income limits NOT qualify for other
insurance
Covers Health maintenance General medical care Medications
DWS offices
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CASE #2
An 8 year old who was born in Mexico comes to theemergency department. He has spina bifida andhas the need for many services.
Where should he go for primary care?
Where should he go for specialty services?
Where can he fill his medications for the lowest
cost?
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PRIMARY VS. SHRINERSPENNIES HOSPITAL
PCMC charity program Covers care at PCMC
Referrals, tests,prescriptions
Criteria Child Poor Citizenship is irrelevant
Patient Accounts-PCMC
Regional charityprogram
Covers care atShriners
Criteria < 18 yo Lives w/in region Chronic orthopedic
condition in SLC
Burns at other ShrinersHospital Citizenship is irrelevant
Contact ShrinersHospital
http://www.shrinershq.org/Hospitals/_Hospitals_for_Children/http://www.shrinershq.org/Hospitals/_Hospitals_for_Children/http://www.shrinershq.org/Hospitals/_Hospitals_for_Children/http://www.shrinershq.org/Hospitals/_Hospitals_for_Children/http://www.shrinershq.org/Hospitals/_Hospitals_for_Children/ -
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INSURANCE REVIEW
Local Programs
Primary Pennies
Shriners Hospital Health Access Project (HAP)
Intermountain Charity Services
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CASE #3
A 2 year old comes into the acute care clinic with afever and crying with urination. Her UA is positivefor leukocyte esterase and nitrites. You are goingto presumptively treat her with antibiotics. She has
not had an UTI in the past. Her Medicaid is pending.
What antibiotic do you prescribe?
What do you tell the family about in terms of whatwill be paid for with Medicaid pending?
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MEDICATIONSCOMMONLYUSEDFORTREATINGAUTI
All suspensions more expensive as are chewabletabs
Cefdinir - $48 for a 125 mg/5ml bottle generic,$97 per bottle brand name
Cefixime $293.00 for 100mg/5 ml bottle
Amoxicillin/Clav - $36 for 600/5 75 ml bottle
Trim/Sulfa- $4 program
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CASE #4
A 6 year old with asthma comes into the hospital foran acute exacerbation.
While in the hospital your attending tells you toorder the following tests:
CBC with diff
Respiratory Panel
Mg
How much do they cost?
He is insured.
You are going to start a controller, what will youchoose?
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ASTHMAMEDICATIONSANDSUPPLIES
Albuterol
Inhaler - $25 - $58 200 actuations
Neb solution - $4 for 75 vials
Spacer with mask - $56
Inhaled steroids
Flovent - $119- $152
QVAR $91- $110 (120 actuations)
Inhalers are all the same size, so if you give apatient 1 puff of Flovent 110 mcg twice daily insteadof 2 puffs of Flovent 44 mcg twice daily, you savethem of their co-pays or, $35x6 = $210 per year