Mohamadou Preveiw

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 189 achieve optimal oral health. The barriers to oral health include lack of access to care whether because of limited income or lack of insurance, transporta- tion, or the flexibility to take time off from work to attend to personal or family needs for care. Individuals with disabilities and those with complex health problems may face additional barriers to care. Sometimes too the public, policy makers, and providers may consider oral health and the need for care to be less important than other health needs, pointing to the need to raise awareness and improve health literacy. Even more costly to the individual and to society are the expenses associ- ated with oral health problems that go beyond dental diseases. However, add to that expense the tens of billions of dollars in direct medical care and indirect costs of chronic craniofacial pain conditions. Then add the social and psychological consequences and costs. Damage to the craniofacial com- plex whether from disease, disorder, or injury strikes at our very identity. We see ourselves and others see us in terms of the face we present to the world. Diminish that image in any way and we risk the loss of self-esteem and well-being. Many unanswered questions remain for scientists, practitioners, educa- tors, policy makers, and the public. Along with the quest for answers comes the challenge of applying what is already known in a society where there are social, political, economic, behavioral, and environmental barriers to health and well-being. Although theorists have proposed a variety of models of health determi- nants, there is general consensus that individual biology, the physical and socioeconomic environment, personal behaviors and lifestyle, and the or- ganization of health care are key factors whose interplay determines the level of oral health achieved by an individual. This chapter provides examples of these factors with an emphasis on barriers and ways to raise the level of oral health for children and older Americans. The findings include: • The major factors that determine oral and general health and well-

190 MOHAMADOU M. DIENE being are individual biology and genetics, the environment, in- cluding its physical and socioeconomic aspects, personal behaviors and lifestyle, access to care, and the organization of health care. These factors interact over the life span and determine the health of individuals, population groups, and communities—from neigh- borhoods to nations. • The burden of oral diseases and conditions is disproportionately borne by individuals with low socioeconomic status at each life stage and by those who are vulnerable because of poor general health. • Access to care makes a difference. A complex set of factors under- lies access to care and includes the need to have an informed pub- lic, the need to have informed policy makers, integrated and cul- turally competent programs, and resources to pay and reimburse for the care. Among other factors, the availability of insurance in- creases access to care. • Preventive interventions such as protective head and mouth gear and dental sealants exist but are not uniformly used or reinforced. • Some nursing homes and other long-term care institutions have limited capacity to deliver needed oral health services to their resi- dents, most of whom are at increased risk for oral diseases. • Anticipatory guidance, risk assessment and management facilitate care for children and for the elderly. • Federal and state assistance programs for selected oral health ser- vices exist; however, the scope of services is severely limited and their reimbursement level for oral health services is low compared to the usual fee for care. IN SUMMARY The past half century has seen the meaning of oral health evolve from a narrow focus on teeth and gingiva to the recognition that the mouth is the

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 191 center of vital tissues and functions that are critical to total health and well- being across the life span. The mouth as a mirror of health or disease, as a sentinel or early warning system, as an accessible model for the study of other tissues and organs, and as a potential source of pathology affecting other systems and organs has been described in many research studies and provides the impetus for extensive future research. Past discoveries have en- abled Americans today to enjoy far better oral health than their forebears a century ago. But the evidence that not all Americans have achieved the same level of oral health and well-being stands as a major challenge, one that de- mands the best efforts of public and private agencies and individuals.The call to action invites groups to expand plans, activities, and programs de- signed to promote oral health, prevent disease for all, and improve the qual- ity of life. In addition, special efforts should be made to eliminate the health disparities that affect members of certain racial and ethnic groups and peo- ple who are poor, geographically isolated, or vulnerable because of special oral health care needs. The actions taken to achieve these goals are to be science-based, culturally sensitive, and routinely evaluated. Furthermore, the call to action urges that these emerging oral health plans and activities should be designed with the intent of integrating them into plans for en- hancing general health and well-being. The call to action specifies five specific actions, each of which has an im- plementation strategy. Action 1. Change perceptions of oral health. Americans should understand that oral health is essential to general health and well-being. In addition, their oral health literacy should be enhanced so that they can make informed health-related decisions. Groups to be targeted with educational messages include the general public, health providers, and public policy makers.

192 MOHAMADOU M. DIENE Action 2. Overcome barriers by replicating effective programs and proven efforts. Safe and effective oral disease prevention methods are known but these have not been applied as widely as possible. Community-based health promotion and disease prevention programs should be expanded, and additional out- reach and community service activities are needed to close gaps in access to care. Concerted efforts are needed to overcome barriers in access to care caused by geographic isolation, poverty, insufficient education, and lack of language skills. Inadequate reimbursements for care in some public and private programs should be addressed to encourage additional provider participation. Action 3. Build the science base and accelerate science transfer. Biomedical and behavioral research provides the foundation for an evolving health care practice that includes prevention, diagnosis, and treatment of oral diseases. Future research should address gaps in applied science and science transfer. Applied research including clinical and population-based studies, demonstration projects, and health services research should be enhanced to improve oral health and prevent disease. In addition, the effective transfer of science into public health and private practice should be accelerated. Action 4. Increase oral health workforce diversity, capacity, and flexibility. Multiple strategies are needed to attract members of under- represented ra- cial and ethnic groups to careers in oral health, to ensure availability of suf- ficient numbers of practitioners, educators, and researchers to meet present and future patient and community needs. Oral health workforce capacity also should be enhanced in health care shortage areas and in public health programs. Strategies should address ways to permit optimal flexibility in employment of the oral health workforce to maximize effectiveness.

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 193 Action 5. Increase collaborations. The private and public sectors each have unique characteristics and strengths. Linking the two can result in a creative synergy capitalizing on the talent and resources of each partner. A sustained effort is needed to build the nation’s oral health infrastructure to ensure that all sectors of society— the public, private practitioners, and federal and state government person- nel—have sufficient knowledge, expertise, and resources to design, imple- ment, and monitor oral health programs. HEALTHY PEOPLE 2020: ORAL HEALTH OBJECTIVES Healthy People is the federal government’s agenda to promote health and prevent disease nationwide. Healthy People 2020 identifies the most signifi- cant preventable threats to health in this first decade of the 21st century and establishes national goals to reduce these threats. Goal To prevent and control oral and craniofacial diseases, conditions, and inju- ries, and improve access to preventive services and dental care. Objectives in this topic area address a number of areas for public health improvement including the need to: • Increase awareness of the importance of oral health to overall health and well-being. • Increase acceptance and adoption of effective preventive interventions. • Reduce disparities in access to effective preventive and dental treat- ment services.

194 MOHAMADOU M. DIENE UNDERSTANDING ORAL HEALTH Good self-care such as brushing with fluoride toothpaste, daily flossing, and professional treatment is key to good oral health. Individual behaviors that can lead to poor oral health include: • Tobacco use • Excessive alcohol use • Poor dietary choices Barriers that can limit a person’s use of preventive interventions and treat- ments include: • Limited access to and availability of dental services • Lack of awareness of the need for care • Cost • Fear of dental procedures There are also social determinants that affect oral health. In general, people with lower levels of education and income, and people from specific ra- cial/ethnic groups have higher rates of disease. People with disabilities and other health conditions, like diabetes, are more likely to have poor oral health. GET THE MOST OUT OF YOUR DENTAL VISIT Dental visits aren’t just for cavities and teeth cleaning anymore. During a check-up, your dental hygienist and dentist assess the overall health of your mouth and gums. “A dental check-up is an essential part of preventive care.” Here are five ways to get more out of your next visit to the dentist. 1. Make a checklist of questions or concerns Be prepared with questions you’d like to ask your dentist or hygienist. Be

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 195 sure to mention any of the following problems: • Bleeding when you brush. Bleeding is a common symptom of gum disease. The earlier the disease is caught, the easier it is to treat. • Pain or sensitivity. Tooth pain or unusual sensitivity when biting down or eating hot or cold foods can be a sign of a cracked teeth, broken fillings, or cavities. • Sores inside your mouth that don’t heal normally. Sores that don’t heal may be an early warning sign of oral cancer. Early detection is crucial to find oral cancer when it’s more easily treated. • Problems with flossing or brushing. A jagged tooth or broken fill- ing can make it difficult to floss. Arthritis or other medical condi- tions may make it hard to brush. Your dental team can help find the source of the problem and offer solutions. • Clenching your jaw or grinding your teeth. Many people clench their jaws or grind their teeth, especially at night. Over time, grind- ing and clenching can wear teeth down, damaging the enamel and making teeth more susceptible to decay. Talk to your dentist if you think you grind your teeth. 2. Update your medical history • Make sure your dentist and dental hygienist know your complete medical history. Common conditions like diabetes can affect the health of your gums and teeth. Some medical problems can lead to dry mouth, which increases your risk of cavities. Alert your doctor to any changes in your health since your previous visit. The more your dentist knows about your overall health, the better able he or she will be to give you personalized care

196 MOHAMADOU M. DIENE 3. List all medicines, vitamins, and supplements you take • Certain prescription drugs for allergies, high blood pressure, or de- pression can cause dry mouth, which increases the risk of tooth de- cay and gum problems. Some medications and dietary supplements can thin your blood, increasing the risk of bleeding when you have dental work done. It’s very important for your dental team to know about all the pills you take, including supplements that you may not think of as serious medicine. 4. If money is tight, ask about low-cost options • When household budgets are strained some people put off dental visits. That can lead to problems that are far more expensive than preventive care. If you are having trouble paying for dental care, talk to your dentist about low-cost options or extended payment plans. 5. Find out what you can do better • The field of dental health is constantly changing. New products continue to come along that make oral hygiene easier and more ef- fective. New research provides insights into the best ways to keep teeth and gums healthy. Ask your dentist about anything you should be doing to improve your oral health. Having health insurance gives you access to dental health and other health care services you need.

CHAPTER 27 HEALTH INSURANCE IN THE UNITED STATES In the United States, health insurance is any program that helps pay for medical expenses, whether through privately purchased insurance, so- cial insurance or a social welfare program funded by the government. Synonyms for this usage include “health coverage,” “health care coverage” and “health benefits.” In a more technical sense, the term is used to describe any form of insur- ance that provides protection against the costs of medical services. This us- age includes private insurance and social insurance programs such as Med- icare which pools resources and spreads the financial risk associated with major medical expenses across the entire population to protect everyone as well as social welfare programs such as Medicaid and the State Children’s

198 MOHAMADOU M. DIENE Health Insurance Program which provide assistance to people who cannot afford health coverage. In addition to medical expense insurance, “health insurance” may also refer to insurance covering disability or long-term nursing or custodial care needs. Different health insurance provides different levels of financial pro- tection and the scope of coverage can vary widely with more than 40 percent of insured individuals reporting that their plans do not adequately meet their needs as of 2007. The share of Americans with health insurance has been steadily declining since at least 2000. As of 2010 just under 84% of Americans had some form of health insurance which meant that more than 49 million people went without coverage for at least part of the year. Declining rates of coverage and underinsurance are largely attributable to rising insurance costs and high unemployment. As the pool of people with private health insurance has shrunk, Americans are increasingly reliant on public insurance. Public programs now cover 31% of the population and are responsible for 44% of health care spending. Public insurance programs tend to cover more vul- nerable people with greater health care needs. Many of the reforms insti- tuted by the Affordable Care Act of 2010 were designed to extend health care coverage to those without it. MANAGED CARE The term managed care or managed healthcare is used in the United States to describe a variety of techniques intended to reduce the cost of providing health benefits and improve the quality of care (“managed care techniques”) for organizations that use those techniques or provide them as services to other organizations (“managed care organization” or “MCO”), or to de- scribe systems of financing and delivering healthcare to enrollees organized around managed care techniques and concepts (“managed care delivery sys- tems”). Managed care is intended to reduce unnecessary health care costs through a variety of mechanisms including:

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 199 • economic incentives for physicians and patients to select less costly forms of care. • programs for reviewing the medical necessity of specific services. • increased beneficiary cost sharing. • controls on inpatient admissions and lengths of stay. • the establishment of cost-sharing incentives for outpatient surgery. • selective contracting with health care providers. • And the intensive management of high-cost health care cases. The programs may be provided in a variety of settings such as Health Maintenance Organizations and Preferred Provider Organizations. The growth of managed care in the U.S. was spurred by the enactment of the Health Maintenance Organization Act of 1973 . While managed care techniques were pioneered by health maintenance organizations, they are now used by a variety of private health benefit programs. Managed care is now nearly ubiquitous in the U.S. but has attracted controversy because it has had mixed results in its overall goal of controlling medical costs. Propo- nents and critics are also sharply divided on managed care’s overall impact on the quality of U.S. health care delivery. HISTORY Dr. Paul Starr suggests in his analysis of the American healthcare system (i.e.,The Social Transformation of American Medicine) that Richard Nixon was the first mainstream political leader to take deliberate steps to change American health care from its longstanding not-for- profit business princi- ples into a for-profit model that would be driven by the insurance industry. In 1973 Congress passed the Health Maintenance Organization Act which encouraged rapid growth of Health Maintenance Organizations (HMOs), the first form of managed care. Managed care plans are widely credited with subduing medical cost in- flation in the late 1980s by reducing unnecessary hospitalizations, forcing providers to discount their rates, and causing the health-care industry to

200 MOHAMADOU M. DIENE become more efficient and competitive. Managed care plans and strategies proliferated and quickly became nearly ubiquitous in the U.S. However, this rapid growth led to a consumer backlash. Because many managed care health plans are provided by for-profit companies, their cost-control efforts created widespread perception that they were more interested in saving money than providing health care. In a 2004 poll by the Kaiser Family Foundation, a majority of those polled said they believed that managed care decreased the time doctors spend with patients, made it harder for people who are sick to see specialists, and had failed to produce significant health care savings. These public perceptions have been fairly consistent in polling since 1997. The backlash included vocal critics, including disgruntled patients and consumer-advocacy groups who argued that managed care plans were con- trolling costs by denying medically necessary services to patients even in life- threatening situations, or by providing low-quality care. The volume of crit- icism led many states to pass laws mandating managed-care standards. Meanwhile, insurers responded to public demands and political pressure by beginning to offer other plan options with more comprehensive care net- works—according to one analysis, between the years 1970 and 2005 the share of personal health expenditures paid directly out-of-pocket by U.S. consumers fell from about 40 percent to 15 percent. So, although consum- ers faced rising health insurance premiums over the period, lower out-of- pocket costs likely encouraged consumers to use more health care. By the late 1990s, the U.S. per capita healthcare spending began to in- crease again, peaking around 2002. Despite managed care’s mandate to control costs, U.S. healthcare expenditures have continued to outstrip the overall national income, rising about 2.4 percentage points faster than the annual GDP since 1970. Nevertheless, according to the trade association America’s Health Insurance Plans, 90 percent of insured Americans are now enrolled in plans with some form of managed care. The National Directory of Managed Care Organizations, Sixth Edition profiles more than 5,000 plans, including new

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 201 consumer-driven health plans and health savings accounts. In addition 26 states have contracts with MCOs to deliver long-term care for the elderly and individuals with disabilities. The states pay a monthly capitated rate per member to the MCOs that provide comprehensive care and accept the risk of managing total costs. MANAGED CARE TECHNIQUES One of the most characteristic forms of managed care is the use of a panel or network of healthcare providers to provide care to enrollees. Such inte- grated delivery systems typically include one or more of the following: • A set of designated doctors and healthcare facilities, known as a pro- vider network which furnish an array of health care services to en- rollees. • Explicit standards for selecting providers. • Formal utilization review and quality improvement programs. • An emphasis on preventive care. • Financial incentives to encourage enrollees to use care efficiently. • Provider networks can be used to reduce costs by negotiating favor- able fees from providers, selecting cost effective providers, and cre- ating financial incentives for providers to practice more efficiently. A survey issued in 2009 by America’s Health Insurance Plans found that patients going to out-of-network providers are sometimes charged extremely high fees. Other managed care techniques include disease management, case man- agement, wellness incentives, patient education, utilization management and utilization review. These techniques can be applied to both network- based benefit programs and benefit programs that are not based on a pro- vider network.

202 MOHAMADOU M. DIENE MANAGED CARE ORGANIZATIONS (MCOS) There is a continuum of organizations that provide managed care, each op- erating with slightly different business models. Some organizations are made of physicians, while others are combinations of physicians, hospitals, and other providers. Here is a list of common MCOs: • Group practice without walls. • Independent practice association. • Management services organization. • Physician practice management company. TYPES OF NETWORK-BASED MANAGED CARE PROGRAMS There are several types of network-based managed care programs. These range from more restrictive to less restrictive, and include: Managed Care in a Public Setting: (MCPS) Proposed by Richard Evan Steele, the concept is described in the book Managed Care in a Public Setting. The proposed system encompasses both healthcare and social services in a comprehensive system that provides an- swers for those seeking to balance the myriad challenges of balancing care, cost and social conscience. The concept provides a road-map for all of those looking for melding the best of the US managed care movement and the socially funded European systems in a community based system fueled by positive incentive structures for the lowest effective level of care and the high- est possible quality of care. This can be achieved by changing the focus of care and social services away from the ultra-specialized, evidence based con- cept to a highly tuned, flexible and technically advanced primary care system.

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 203 HEALTH MAINTENANCE ORGANIZATION: (HMO) Proposed in the 1960s by Dr. Paul Elwood in the “Health Maintenance Strategy”, the HMO concept was promoted by the Nixon Administration as a fix to rising health care costs and set in law as the Health Maintenance Organization Act of 1973. As defined in the act, a federally qualified HMO would in exchange for a subscriber fee –premium- allow members access to a panel of employed physicians or a network of doctors and facilities includ- ing hospitals. In return the HMO received mandated market access and could receive federal development funds. Health Maintenance Organiza- tions are licensed at the state level under a license that is known as a certifi- cate of authority (COA) rather than under an insurance license. In practice, an HMO is a coordinated delivery system that combines both the financing and delivery of health care for enrollees. In the design of the plan, each member is assigned a “gatekeeper” who is a primary care physician (PCP) who is responsible for the overall care of members assigned to him/her. Spe- cialty services require a specific referral from the PCP to the specialist. Non-emergency hospital admissions also required specific pre-authoriza- tion by the PCP. Typically services are not covered if performed by a provider not an em- ployee of or specifically approved by the HMO unless it is an emergency situation as defined by the HMO. Financial sanctions for use of emergency facilities in non-emergency situations were once an issue. However, prudent layperson language now applies to all emergency-service utilization and penalties are rare. INDEPENDENT PRACTICE ASSOCIATION (IPA) An Independent Practice Association is a legal entity that contracts with a group of physicians to provide service to the HMO’s members. Most often, the physicians are paid on a basis of capitation which in this context means a set amount for each enrolled person assigned to that physician or group

204 MOHAMADOU M. DIENE of physicians whether or not that person seeks care. The contract is not usually exclusive, thus allowing individual doctors or the group to sign con- tracts with multiple HMOs. Physicians who participate in IPAs usually also serve fee-for-service patients not associated with managed care. IPAs usually have a governing board to determine the best forms of practices. PREFERRED PROVIDER ORGANIZATION (PPO) Rather than contract with the various insurers and third party administra- tors, providers may contract with preferred provider organizations. A mem- bership allows a substantial discount below their regularly charged rates from the designated professionals partnered with the organization. Pre- ferred provider organizations themselves earn money by charging an access fee to the insurance company for the use of their network (unlike the usual insurance with premiums and corresponding payments paid either in full or partially by the insurance provider to the medical doctor). In terms of using such a plan, unlike an HMO plan which has a copay- ment cost share feature (a nominal payment generally paid at the time of service), a PPO generally does not have a copay and instead offers a deduct- ible and a coinsurance feature. The deductible must be paid in full before any benefits are provided. After the deductible is met, the coinsurance ben- efits apply. If the PPO plan is an 80% coinsurance plan with a $1,000 de- ductible, then the patient will pay 100% of the allowed provider fee up to $1,000. After this amount has been paid by the patient, the insurer will pay 80% of subsequent fees and the patient will pay the remaining 20%. Charges above the allowed amount are not payable by the patient or in- surer but instead are written off as a discount by the physician. POINT OF SERVICE (POS) A POS plan utilizes some of the features of each of the above plans. Mem- bers of a POS plan do not make a choice about which system to use until the point at which the service is being used. In terms of using such a plan,

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 205 a POS plan has levels of progressively higher patient financial participation as the patient moves away from the more managed features of the plan. For example, if the patient stays in a network of providers and seeks a referral to use a specialist, they may have a copayment only. However, if they use an out of network provider, but do not seek a referral, they will pay more, and so on. POS plans are becoming more popular because they offer more flexibility and freedom of choice than standard HMOs. PRIVATE FEE-FOR-SERVICE (PFFS) There are basically two types of Health Insurance: Fee-for-Service (indem- nity) and Managed Care. Health insurance policies may vary from low cost to all-inclusive, meeting different demands of customers. Which health in- surance type and plan you choose largely depends on your needs, prefer- ences and budget. Fee-for-Service is a traditional kind of health care policy wherein insurance companies pay medical staff fees for each service pro- vided to an insured patient. Fee-for-service plans offer a wide choice of doc- tors and hospitals. Fee-for-Service coverage falls into basic and major medical protection categories. Basic protection deals with costs of a hospital room, hospital ser- vices, care and supplies, cost of surgery in or out of hospital, and doctor visits. Major medical protection covers costs of serious illnesses and injuries, which usually require long-term treatment and rehabilitation period. Basic and major medical insurance coverage combined are called a comprehensive health care plan. It is vitally important to know your insurance policy, since some services can be limited and some not covered at all. MANAGED CARE IN INDEMNITY INSURANCE PLANS Many “traditional” or “indemnity” health insurance plans now incorporate some managed care features such as precertification for non-emergency

206 MOHAMADOU M. DIENE hospital admissions and utilization reviews. These are sometimes described as “managed indemnity” plans. Impacts The overall impact of managed care remains widely debated. Proponents argue that it has increased efficiency, improved overall standards, and led to a better understanding of the relationship between cost and quality. They argue that there is no consistent, direct correlation between the cost of care and its quality, pointing to a 2002 Juran Institute study which estimated that the “cost of poor quality” caused by overuse, misuse, and waste amounts to 30 percent of all direct healthcare spending. The emerging prac- tice of evidence-based medicine is being used to determine when lower-cost medicine may in fact be more effective. Critics of managed care argue that “for-profit” managed care has been an unsuccessful health policy, as it has contributed to higher health care costs (25–33% higher overhead at some of the largest HMOs), increased the number of uninsured citizens, driven away health care providers, and ap- plied downward pressure on quality (worse scores on 14 of 14 quality indi- cators reported to the National Committee for Quality Assurance). Others argue that managed care puts the emphasis on financial implications instead of healthcare. In hospital meetings, it has been reported that senior staff feel “the only people with real decisions to make are the insurers.” The most common managed care financial arrangement, capitation, places healthcare providers in the role of micro-health insurers, assuming the responsibility for managing the unknown future health care costs of their patients. Small insurers like individual consumers tend to have annual costs that fluctuate far more than larger insurers. The term “Professional Caregiver Insurance Risk” explains the inefficiencies in health care finance that result when in- surance risks are inefficiently transferred to health care providers who are expected to cover such costs in return for their capitation payments. Capitation is a payment arrangement for health care service providers such as physicians or nurse practitioners. It pays a physician or group of

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 207 physicians a set amount for each enrolled person assigned to them per pe- riod of time whether or not that person seeks care. These providers generally are contracted with a type of health maintenance organization (HMO) known as an independent practice association (IPA) which enlists the pro- viders to care for HMO- enrolled patients. The amount of remuneration is based on the average expected health care utilization of that patient, with greater payment for patients with significant medical history.

CHAPTER 28 WHAT IS MEDICARE / MEDICAID? Medicaid and Medicare are two governmental programs that pro- vide medical and health-related services to specific groups of people in the United States. Although the two programs are very different, they are both managed by the Centers for Medicare and Medicaid Services, a division of the U.S. Department of Health and Human Services. Medicare is a social insurance program that serves more than 44 million enrollees (as of 2008). The program costs about $432 billion, or 3.2% of GDP, in 2007. Medicaid is a social welfare (or social protection) program that serves about 40 million people (as of 2007) and costs about $330 bil- lion, or 2.4% of GDP, in 2007. Both Medicaid and Medicare were created when President Lyndon B. Johnson signed amendments to the Social Security Act on July 30, 1965.

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 209 WHAT IS MEDICAID? Medicaid is a means-tested health and medical services program for certain individuals and families with low incomes and few resources. Primary over- sight of the program is handled at the federal level, but each state: • Establishes its own eligibility standards, • Determines the type, amount, duration, and scope of services, • Sets the rate of payment for services, and • Administers its own Medicaid program. What services are provided with Medicaid? Although the States are the final deciders of what their Medicaid plans pro- vide, there are some mandatory federal requirements that must be met by the States in order to receive federal matching funds. Required services in- clude: • Inpatient hospital services. • Outpatient hospital services. • Prenatal care. • Vaccines for children. • Physician services. • Nursing facility services for persons aged 21 or older. • Family planning services and supplies. • Rural health clinic services. • Home health care for persons eligible for skilled-nursing services. • Laboratory and x-ray services. • Pediatric and family nurse practitioner services. • Nurse-midwife services. • Federally qualified health-center (FQHC) services and ambulatory services. • Early and periodic screening, diagnostic, and treatment (EPSDT)

210 MOHAMADOU M. DIENE services for children under age 21. States may also provide optional services and still receive Federal match- ing funds. The most common of the 34 approved optional Medicaid ser- vices are: • Diagnostic services. • Clinic services. • Intermediate care facilities for the mentally retarded (ICFs/MR). • Prescribed drugs and prosthetic devices. • Optometrist services and eyeglasses. • Nursing facility services for children under age 21. • Transportation services. • Rehabilitation and physical therapy services. • Home and community-based care to certain persons with chronic impairments. WHO IS ELIGIBLE FOR MEDICAID? Each state sets its own Medicaid eligibility guidelines. The program is geared towards people with low incomes, but eligibility also depends on meeting other requirements based on age, pregnancy status, disability sta- tus, other assets, and citizenship. States must provide Medicaid services for individuals who fall under cer- tain categories of need in order for the state to receive federal matching funds. For example, it is required to provide coverage to certain individuals who receive federally assisted income-maintenance payments and similar groups who do not receive cash payments. Other groups that the federal government considers “categorically needy” and who must be eligible for Medicaid include:

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 211 • Individuals who meet the requirements for the Aid to Families with Dependent Children (AFDC) program that were in effect in their state on July 16, 1996. • Children under age 6 whose family income is at or below 133% of the Federal poverty level (FPL). • Pregnant women with family income below 133% of the FPL. • Supplemental Security Income (SSI) recipients. • Recipients of adoption or foster care assistance under Title IV of the Social Security Act. • Special protected groups such as individuals who lose cash assis- tance due to earnings from work or from increased Social Security benefits. • Children born after September 30, 1983 who are under age 19 and in families with incomes at or below the FPL. • Certain Medicare beneficiaries. States may also choose to provide Medicaid coverage to other similar groups that share some characteristics with the ones stated above but are more broadly defined. These include: • Infants up to age 1 and pregnant women whose family income is no more than a state-determined percentage of the FPL • Certain low-income and low-resource children under the age of 21 • Low-income institutionalized individuals • Certain aged, blind, or disabled adults with incomes below the FPL • Certain working-and-disabled persons with family income less than 250 percent of the FPL • Some individuals infected with tuberculosis • Certain uninsured or low-income women who are screened for breast or cervical cancer

212 MOHAMADOU M. DIENE • Certain “medically needy” persons, which allow states to extend Medicaid eligibility to persons who would be eligible for Medicaid under one of the mandatory or optional groups, except that their income and/or resources are above the eligibility level set by their state. Medicaid does not provide medical assistance for all poor persons. In fact, it is estimated that about 60% of America’s poor are not covered by the program. WHO PAYS FOR SERVICES PROVIDED BY MEDICAID? Medicaid does not pay money to individuals but operates in a program that sends payments to the health care providers. States make these payments based on a fee-for-service agreement or through prepayment arrangements such as health maintenance organizations (HMOs). Each state is then reimbursed for a share of their Medicaid expenditures from the Federal Government. This Federal Medical Assistance Percentage (FMAP) is determined each year and depends on the State’s average per capita income level. Richer states receive a smaller share than poorer states, but by law the FMAP must be between 50% and 83%. States may impose nominal deductibles, coinsurance, or copayments on some Medicaid beneficiaries for certain services. However, the following Medicaid beneficiaries must be excluded from cost sharing: • Pregnant women, • Children under age 18, and • Hospital or nursing home patients who are expected to contribute most of their income to institutional care. All Medicaid beneficiaries must be exempt from copayments for emer- gency services and family planning services.

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 213 WHAT IS MEDICARE? Medicare is a federal health insurance program for: • people age 65 or older, • people under age 65 with certain disabilities, and • people of all ages with End-Stage Renal Disease (permanent kid- ney failure requiring dialysis or a kidney transplant). The program consists of two main parts for hospital and medical insur- ance (Part A and Part B) and two additional parts that provide flexibility and prescription drugs (Part C and Part D). Medicare Part A, or Hospital Insurance (HI), helps pay for hospital stays which includes meals, supplies, testing, and a semi-private room. This part also pays for home health care such as physical, occupational, and speech therapy that is provided on a part-time basis and deemed medically neces- sary. Care in a skilled nursing facility as well as certain medical equipment for the aged and disabled such as walkers and wheelchairs are also covered by Part A. Part A is generally available without having to pay a monthly premium since payroll taxes are used to cover these costs. Medicare Part B is also called Supplementary Medical Insurance (SMI). It helps pay for medically necessary physician visits, outpatient hospital visits, home health care costs, and other services for the aged and disabled. For example, Part B covers: • Durable medical equipment (canes, walkers, scooters, wheelchairs, etc.). • Physician and nursing services. • X-rays, laboratory and diagnostic tests. • Certain vaccinations. • Blood transfusions.

214 MOHAMADOU M. DIENE • Renal dialysis. • Outpatient hospital procedures. • Some ambulance transportation. • Immunosuppressive drugs after organ transplants. • Chemotherapy. • Certain hormonal treatments. • Prosthetic devices and eyeglasses. Part B requires a monthly premium ($104.90 in 2016), and patients must meet an annual deductible ($166.00 in 2016) before coverage actually begins. Enrollment in Part B is voluntary. Medicare Advantage Plans (sometimes known as Medicare Part C, or Medicare + Choice) allow users to design a custom plan that can be more closely aligned with their medical needs. These plans enlist private insurance companies to provide some of the coverage, but details vary based on the program and eligibility of the patient. Some Advantage Plans team up with health maintenance organiza- tions (HMOs) or preferred provider organizations (PPOs) to provide pre- ventive health care or specialist services. Others focus on patients with spe- cial needs such as diabetes. In 2006, Medicare expanded to include a prescription drug plan known as Medicare Part D. Part D is administered by one of several private insur- ance companies, each offering a plan with different costs and lists of drugs that are covered. Participation in Part D requires payment of a premium and a deductible. WHAT ABOUT SERVICES THAT ARE NOT PROVIDED THROUGH MEDICARE? Supplemental coverage for medical expenses and services that are not covered by Medicare are offered through MediGap plans. MediGap consists of twelve plans that the Centers for Medicare and Medicaid Services have authorized private companies to sell and administer. Since the

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 215 availability of Medicare Part D, MediGap plans are no longer able to include drug coverage. WHO IS ELIGIBLE FOR MEDICARE? To be eligible for Medicare, an individual must either be at least 65 years old, under 65 and disabled, or of any age with End-Stage Renal Disease (permanent kidney failure that requires dialysis or a transplant.) In addition, eligibility for Medicare requires that an individual is a U.S. citizen or permanent legal resident for five continuous years and is eligible for Social Security benefits with at least ten years of payments contributed into the system. Who pays for services provided by Medicare? Payroll taxes collected through FICA (Federal Insurance Contributions Act) and the Self-Employment Contributions Act are a primary component of Medicare funding. The tax is 2.9% of wages usually half paid by the employee and half paid by the employer. Moneys are set aside in a trust fund that the government uses to reimburse doctors, hospitals, and private insurance companies. Additional funding for Medicare services comes from premiums, deductibles, coinsurance, and copays.

CHAPTER 29 THE AFFORDABLE CARE ACT The Patient Protection and Affordable Care Act (PPACA), com- monly called the Affordable Care Act (ACA) or Obamacare, is a United States federal statute enacted by President Barack Obama on March 23, 2010. Together with the Health Care and Education Recon- ciliation Act amendment, it represents the most significant regulatory over- haul of the U.S. healthcare system since the passage of Medicare and Med- icaid in 1965. Under the act, hospitals and primary physicians would trans- form their practices financially, technologically, and clinically to drive better health outcomes, lower costs, and improve their methods of distribution and accessibility. The Affordable Care Act was intended to increase health insurance quality and affordability, lower the uninsured rate by expanding

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 217 insurance coverage and reduce the costs of healthcare. It introduced mech- anisms including mandates, subsidies and insurance exchanges. The law re- quires insurers to accept all applicants, cover a specific list of conditions and charge the same rates regardless of pre-existing conditions or sex. In 2011, the Congressional Budget Office projected that the ACA would lower fu- ture deficits and Medicare spending. The law and its implementation faced challenges in Congress and federal courts, and from some state govern- ments, conservative advocacy groups, labor unions, and small business or- ganizations. The United States Supreme Court upheld the constitutionality of the ACA’s individual mandate as an exercise of Congress’s taxing power, that states cannot be forced to participate in the ACA’s Medicaid expansion, and that the law’s subsidies to help individuals pay for health insurance are available in all states, not just in those that have set up state exchanges. In March 2015, the Centers for Disease Control and Prevention reported that the average number of uninsured during the period from January to Sep- tember 2014 was 11.4 million fewer than the average in 2010. In April 2016, Gallup reported that the percentage of adults who were uninsured dropped from 18% in the third quarter of 2013 to 11% in the first quarter of 2016. ABOUT THE LAW The Affordable Care Act puts consumers back in charge of their health care. Under the law, a new “Patient’s Bill of Rights” gives the American people the stability and flexibility they need to make informed choices about their health. KEY FEATURES OF THE AFFORDABLE CARE ACT The law put in place comprehensive health insurance reforms that put con- sumers back in charge of their health care. A new wave of powerful evidence points to one clear conclusion: the Affordable Care Act is working to make health care more affordable, accessible and of a higher quality for families,

218 MOHAMADOU M. DIENE seniors, businesses, and taxpayers alike. This includes previously uninsured Americans, and Americans who had insurance that didn’t provide them ad- equate coverage and security. BENEFITS OF THE AFFORDABLE CARE ACT FOR AMERICANS Improving Quality and lowering Health Care Costs: • Free preventive care. • Prescription discounts for seniors. • Protection against health care fraud. • Small business tax credits. New Consumer Protections: • Pre-existing conditions Access to Health Care: • Health Insurance Marketplace. Benefits for Women: • Providing insurance options. • Covering preventive services. • Lowering costs. Young Adult Coverage: • Coverage available to children up to age 26. Strengthening Medicare: • Yearly wellness visit. • Many free preventive services for some seniors with Medicare. Holding Insurance Companies Accountable:

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 219 • Insurers must justify any premium increase of 10% or more before the rate takes effect.

CHAPTER 30 CONCLUSION On June 22, 2010, President Obama announced new interim final regulations, the Patient’s Bill of Rights that include a set of pro- tections that apply to health coverage starting on or after Septem- ber 23, 2010, six months after the enactment of the Affordable Care Act. The Departments of Health and Human Services, Labor and Treasury col- laborated on the Patient’s Bill of Rights – which will help children -and eventually all Americans- with pre-existing conditions gain coverage and keep it, protect all Americans’ choice of doctors, and end lifetime limits on the care consumers may receive. These new protections create an important foundation of patients’ rights in the private health insurance market that puts Americans in charge of their own health. When an organization values, recognizes, and respects patient rights, it is providing an important aspect of care that has been shown to encourage patients to become more informed and involved in their own care. These empowered patients ask questions and develop better relationships with

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 221 their caregivers. This acknowledgement of patient rights also helps patients feel supported by the organization and those people directly involved in their care. Recognizing and respecting patient rights can directly affect the provision of care. Care, treatment, or services should be provided in a way that re- spects and fosters the patient’s dignity, autonomy, positive self-regard, civil rights, and involvement in his or her care. Care, treatment, and services should also be carefully planned and provided with regard to the patient’s personal values, beliefs, and preferences. Recognizing and respecting patient rights are, however, only part of the story. Patients also have the obligation to take on certain responsibilities. The organization can help define these responsibilities and then relay them to the patient. When patients under- stand and accept their responsibilities, the concept of the patient as a partner in care becomes a dynamic component of the interaction between patient and treatment provider. A mere list of patient rights cannot by itself guarantee those rights. The organization shows its support of patient rights through its interactions with patients and by involving them in decisions about their care, treatment, and services. Currently, attempts are being made by the Trump administration to re- peal Obamacare.



ABOUT THE AUTHOR Dr. Mohamadou M. Diene, MD, MPH is a Senegalese born physician now living in New York. Dr. Diene has a Master of Public Health from the New York Medical College, School of Public Health, in Valhalla, NY. Dr. Diene is also a member of the American Society for Quality (ASQ), and an ASQ-Certified Manager of Quality/Organizational Excellence. Dr. Diene has worked in major New York City Hospitals as a Quality Improvement Coordinator, helping to build capacity and improve the qual- ity of care, achieving greater patient satisfaction and better health outcomes.