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ADVOCACY MORNING REPORT

September 16, 2011 WENDY Hobson-Rohrer, MD MSPH

1ST CASE
3 year old comes into your continuity clinic for a visit. Her BMI is less than the 5% and her weight is also below the 5%. You would like to give her increased calories and are considering a supplement. She is uninsured. What questions will you ask to assess which programs she can use? What are the potential programs that she can access? What supplement will you do?

WIC WOMENS INFANTS AND CHILDRENS


PROGRAM 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 the feeds are via G-Tube, then insurance pays for the formula, not WIC

WIC GUIDLINES

INCREASING CALORIES FOR LOW COST


Whole milk 17kcal/oz Carnation instant breakfast with whole milk 30 kcal/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

REASONS TO UNDERSTAND INSURANCE


Refer appropriately Empathy Impacts medical care Personalize care Credibility Advocacy Get paid

VOICES FROM THE 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 your financial limits are.
dont know the price.

Doctors

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

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

2011 HHS Poverty Guidelines


Persons in Family 1 2 3 4 5 6 7 8 For each additional person, add 48 Contiguous States and D.C. $10,890 14,710 18,530 22,350 26,170 29,990 33,810 37,630

Alaska $13,600 18,380 23,160 27,940 32,720 37,500 42,280 47,060

Hawaii $12,540 16,930 21,320 25,710 30,100 34,490 38,880 43,270

3,820

4,780

4,390

SOURCE: Federal Register, Vol. 76, No. 13, January 20, 2011, pp. 3637-3638

Pediatric Insurance Atlas


Citizen or Lawful Permanent Resident
Yes Renal Failure Yes No

No Poor & Either 1) Pregnant OR 2) Life Threatening Disease Yes No Emergency Medicaid Poor No

Medicare Poor <100% FPL Yes No

Yes
Medicaid No Primary Pennies No Low income 101-200% FPL Yes

Chronic Orthopedic Problems or Burns No Yes CHIP

Shriners Hospital

INSURANCE OVERVIEW
State & Federal Programs Local Programs

MEDICARE

VS.

MEDICAID
Federal & State $$
State administered State-determined eligibility criteria Apply at Division of Workforce Services offices

Federal $$
Federally administered National eligibility criteria Apply at Social Security Office

Medicare, Disability, Social Security

Medicaid, Emergency Medicaid, Baby Your Baby, CHIP, PCN, Medicare assistance programs

MEDICARE

VS.

MEDICAID

Citizen/Resident & Social Security Qualifications &


> 65 years old Disabled x 2 yrs Renal Failure

Citizen/Resident & Poor &


<19 or > 65 Disabled or blind Pregnant Parent/caretaker of a child <19 yo Untreated breast/cervical CA

MEDICARE

VS.

MEDICAID

Covers:

Covers:

Minimal health maintenance Symptomatic care Some medications

Health maintenance Symptomatic care Medications

YES: Many different plans

pap, mammo, prostate CA screen, colon CA screen, flu & pneumovax NO: vaccines

Many complex options

State Health Insurance Assistance Program

BABY YOUR BABY


VS.

EMERGENCY MEDICAID
Emergency Services for NonCitizens Emergency services only
Pregnancy (only L&D costs) Life-threatening disease

Presumptive Eligibility Program Short-term (45 d) immediate coverage


While apply for Medicaid One BYB card/pregnancy

Covers:
Prenatal General medical care Medications

Criteria

Poor non-citizens & non-residents of US (including illegal aliens) NO risk to be deported Medicaid offices

US Citizen/Resident + Pregnancy test Income limits

Medicaid & other sites

CHIP

VS.

PCN
Primary Care Network

Childrens Health Insurance Program

State administered Criteria

US Citizen/Resident Child Low-income Not qualify for Medicaid Health maintenance General medical care Medications Now should be open

State administered Replaced UMAP Criteria

Covers

US citizen/resident 19-64 yo Income limits NOT qualify for other insurance

Covers

Open-enrollment

Health maintenance General medical care Medications

DWS offices

DWS offices

CASE #2

An 8 year old who was born in Mexico comes to the emergency department. He has spina bifida and has 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?

PRIMARY PENNIES

VS.

SHRINERS HOSPITAL
Regional charity program Covers care at Shriners Criteria

PCMC charity program Covers care at PCMC

Referrals, tests, prescriptions

Criteria

Child Poor Citizenship is irrelevant

Patient Accounts-PCMC

< 18 yo Lives w/in region Chronic orthopedic condition in SLC Burns at other Shriners Hospital Citizenship is irrelevant

Contact Shriners Hospital

INSURANCE REVIEW

Local Programs
Primary Pennies Shriners Hospital Health Access Project (HAP) Intermountain Charity Services

CASE #3
A 2 year old comes into the acute care clinic with a fever and crying with urination. Her UA is positive for leukocyte esterase and nitrites. You are going to 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 what will be paid for with Medicaid pending?

MEDICATIONS COMMONLY USED FOR


TREATING A UTI

All suspensions more expensive as are chewable tabs

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

CASE #4
A 6 year old with asthma comes into the hospital for an acute exacerbation. While in the hospital your attending tells you to order 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 you choose?

ASTHMA MEDICATIONS AND SUPPLIES

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 a patient 1 puff of Flovent 110 mcg twice daily instead of 2 puffs of Flovent 44 mcg twice daily, you save them of their co-pays or, $35x6 = $210 per year