Advocacy: Access to Care

8/3/2019 Advocacy: Access to Care

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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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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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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

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