Patients insured

Cost is also another related issue for patients. Insurance may not cover all forms of contraception, and patients may have to bear the entire cost for certain options. 

A common example of a service in a community pharmacy is the filling of a prescription that is not compounded. In this case, a pharmacist, with the assistance of technicians and clerks, is adding value to the product that was made by a pharmaceutical company. The pharmacist is packaging the exact amount needed by the patient, adding information that will help the patient to take it appropriately, and billing the patients insurance company for the cost of the prescription. Pharmacists may add additional value to this product, and these value-added services illustrate the similarities to product creation. 

The difference between compensation and reimbursement is one of the first concepts that require further explanation. One of the goals of value-added services is to receive compensation for services. This means that the patient, insurance company, or some other entity has paid for the direct cost of the service plus the perceived value of that service. Reimbursement, on the other hand, is payment for only the direct cost of the service without any payment above that (Hogue, 2002). In order to have a profitable service, compensation should be targeted instead of reimbursement. If only reimbursement is targeted, then only the direct costs of providing the service, such as payment for supplies, is recovered, and the net revenue may be minimal. 

Healthcare providers (physicians, hospitals, clinics, etc.) operate and are sustained by the reimbursement or payment for care they provide to patients. In the United States, revenue for healthcare services comes from a variety of sources including the patient, insurance companies (i.e., Blue-Cross/BlueShield, Cigna, Aetna), and the Centers for Medicare and Medicaid Services (CMS), formerly the Health Care Financing Administration (HCFA). The CMS provides healthcare insurance for Medicare and Medicaid beneficiaries. When interfacing with an insurance company or the CMS, there are three fundamental reimbursement concepts that must be considered to assure appropriate revenue for services provided. These include the concepts of coverage, coding, and payment. 

When addressing quality improvement efforts, we need to recognize the needs of patients, insurers, regulators, patients, and staff. There exists a need to identify priorities for improvement and meet... 

Other factors, such as the patient s age, financial problems that may be associated with a long-term illness, family cooperation and interest in the patient, and the adequacy of health insurance cover-age (which may be of great concern to the patient)... 

Item 16 This section refers to how the person who gave the vaccine purchased it, not to the patient s insurance. 

In countries with an existing (social) health insurance system, it is usually rather simple do receive a close-to-reality estimate of the provider Costs-of-Illness. The insurance pays the bills of general practitioners, specialists, hospitals, pharmacies, laboratories, etc. so that the total costs per patient can easily be determined. However, in some countries we cannot receive this data, and sometimes confidentiality regulations do not permit the transfer of insurance data, so that, for instance, provider costs of difference phases of HIV/AIDS can be calculated. In this case, a sample of patient files has to be analyzed with permission of the patients so that the provider costs can be recorded. 

HelUnger and Fleishman (2000) derived estimates for costs of treating people with HIV disease in the United States using patient-based, payer-based, and provider-based approaches. Based on insurance data from 1996, they calculated average annual cost of treating a person with HIV disease between US 20,000 and US 24,700. 

When sufficient evidence is available to determine that the patient has real seizures and is at risk for another seizure, pharmacotherapy is usually started (Fig. 27-2). The patient should be in agreement with the plan, be willing to take the medication, and be able to monitor seizure frequency and adverse drug effects in some way. Design of an appropriate pharmacotherapeutic plan is based on the patient s seizure type, the common adverse-effect profile of possible AEDs, and economic factors (e.g., cost of the drug, insurance formulary, and ability to pay). Other patient factors such as gender, concomitant drugs, age, and lifestyle also need to be considered. 

Lifestyle modifications should be started early and continued throughout treatment because they may improve ADL, gait, balance, and mental health. The most common interventions include maintaining good nutrition, physical condition, and social interactions. Patients should avoid medications that block central dopamine, as they may worsen PD.1,18 A multidisciplinary approach using the expertise of nutritionists, speech therapists, physical therapists, occupational therapists, and social workers may optimize care but may not be covered by insurance. Patients should maintain regular visits with their optometrist or ophthalmologist and their dentist. The dentist should be informed that the patient has PD, as PD medications that decrease saliva flow may increase the risk of dental caries. 

Biologic response modifiers (BRMs) are indicated in patients who have failed an adequate trial of DMARD therapy.1 BRMs may be added to DMARD monotherapy (i.e., methotrexate) or replace ineffective DMARD therapy.22 The decision to select a particular agent generally is based on the prescriber s comfort level with monitoring the safety and efficacy of the medications, the frequency and route of administration, the patient s comfort level or manual dexterity to self-administer subcutaneous injections, the cost, and the availability of insurance coverage.23 In general, BRMs should be avoided in patients with serious infections, demyelinating disorders (e.g., multiple sclerosis or optic neuritis) or heart failure.21... 

The patient calls back to the clinic the next day. Her insurance company denied coverage for the antihistamine-decongestant combination and also will not cover these as single-entity products. She requests an alternate prescription. 

Since many AR treatment options are available OTC, patients often self-treat unless symptoms are intolerable. Additionally, patients without medical insurance or formulary coverage are more likely to purchase OTC agents. Health care providers should ask patients about OTC medication history (i.e., effectiveness of and adverse effects with previously used agents) when selecting AR therapy. 

Most OTC products cost 10 to 20 per course of therapy. The cost of prescription products can vary based on if and what type of insurance coverage the patient has. 

IBW is the weight expected for a nonobese person of a given height. The IBW formulas below and various life insurance tables can be used to estimate IBW. Dosing methods described in the literature may use IBW as a method in dosing obese patients. 

Costs to the patient and costs of individual products are variable but may be substantial. An epidemiological study of human immunodeficiency virus (HIV)-infected patients found that patients spent an average of 18 per month on herbs (range, 0-175) [46]. Unfortunately most U.S. prescription insurance companies do not cover the cost of dietary supplements. One exception is the American Western Life Insurance Company, San Mateo, California, which offers their subscribers a Prevention Plus option that covers herbal medicines [34]. In Germany, herbs that are prescribed by physicians are covered by insurance, whereas non-prescription herbs are not covered [34]. 

To better understand managed care and the reasons for its growth, it is useful to discuss the evolution of payment mechanisms for health care from no insurance, to traditional indemnity insurance, to managed care. In the no-insurance model, the patient selects a health care provider and then pays the provider directly for health care goods and services. The choice of health care provider and the type and number of services provided are limited only by the financial constraints of the patient. The problem with this model is that the patient is exposed to potentially catastrophic health care expenses. Health insurance was developed as a way to protect patients against this risk. Health insurance often is provided through the employer and prior to the mid-1980s was likely to be indemnity fee-for-service insurance. In this traditional insurance... 

Provider networks are groups of providers under some type of contract with the insurer. Patients choice of provider is restricted, and they may receive only partial coverage or no coverage for health care obtained from providers who are not in the network. Having a contract with a provider network allows the... 

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