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2 - Ethical and Socioeconomic Considerations |
37
The previous paragraphs illustrate cultural
characteristics that have been documented in
the literature as being associated with specific
populations. Although this information is helpful
in working with patients who identify as members
of a population, the clinician must not ignore
that individual patients do not always ascribe
to a population’s collective cultural norm. One
resource that may be helpful in describing and
applying cultural competent care to geriatric
patients is the iGeriatrics smartphone applica-
tion from the American Geriatrics Society.
23
It
includes a Geriatrics Cultural Navigator that
contains information about 15 different ethnic
groups and practice pearls on how to apply the
information to recognize variations in an indi-
vidual from group stereotypes.
Shared Decision Making
Geriatric patients have the right to autonomy in
decision making, but, in reality, geriatric patients
often participate in shared decision making that
involves healthcare providers, family, and care-
givers. As described above, various cultures
approach healthcare decision making as shared
between the individual and one or more of these
groups. However, the patient, if capable, must
make his or her own informed choice. Pharma-
cists must be aware of cultures where strong
extended family bonds or paternalism may over-
shadow an individual’s right to make his or her
own decisions. A patient has the best opportu-
nity to maintain autonomy when working with an
interprofessional team.
Religious and Spiritual Inuences
Religious and spiritual beliefs and practices
influence many patients’ attitudes toward health
and wellness, and the older patient is no excep-
tion. Religion has been noted as being very
important to a majority of Americans age 50 and
older.
24
Religion and spirituality are important
coping mechanisms in the presence of illness
and therapy. Religion is defined as an orga-
nized system of beliefs, practices, and symbols
designed to facilitate closeness to a higher
power and includes the understanding of one’s
relationship with and responsibility to others.
25
The three Abrahamic monotheistic religions,
Judaism, Christianity, and Islam, have carefully
considered positions on medical ethics, and
devotees to these religions often turn to reli-
gious leaders for guidance in biomedical ethical
decision making.
26
Spirituality is defined as the
quest for understanding life’s ultimate questions
and the meaning and purpose of living, which
often leads to the development of rituals and a
shared religious community.
24
Religious and spir-
itual beliefs can help patients cope with illness
and may aid in incorporating health changes
into their lives. An older patient’s religion and/or
spirituality can influence their decision making in
aspects of healthcare and his or her approach
to accepting the recommended course of care.
Healthcare providers should enquire about and
acknowledge the religious and spiritual beliefs
of their patients when making patient care
decisions. Healthcare providers may not share
the same religion and/or spirituality as their
patients, and this may cause misunderstanding
or conflict between the healthcare provider and
the patient.
26
S D M
A D
A surrogate decision maker is an agent who acts
on behalf of a patient who lacks the capacity to
participate in a particular decision.
1
According
to the Patient Self-Determination Act of 1991,
healthcare organizations, including hospitals
and nursing homes, that receive Medicaid and
Medicare funds have the responsibility to explain
to patients, staff, and families (through written
information) that patients have a legal right to
direct their medical and nursing care as it corre-
sponds to existing state laws. This federal regu-
lation requires healthcare organization personnel
to enquire of all adults admitted as inpatients
whether they have an advance directive (AD) for
healthcare and to inform patients of their right to
refuse treatment.
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38
| Fundamentals of Geriatric Pharmacotherapy
The three primary purposes of the Patient Self-
Determination Act are:
• to educate the public about state laws
governing the refusal, withholding, and with-
drawal of treatment at the end of life;
•
to encourage wider use of ADs to prevent
the uncertainty among doctors and family
members that often leads to prolonged
treatment of the dying, and in some cases
to lengthy court battles; and
•
to reduce the costs of treatment at the end
of life by reducing unwanted and unneces-
sary intervention and the perceived need for
defensive medicine.
27,28
All states have regulations concerning ADs,
although their legal requirements may vary. ADs
are specific instructions, prepared beforehand,
that are intended to direct a person’s medical
care if he or she becomes unable to do so in
the future. They allow patients to make their own
decisions and preserve some measure of control
regarding the medical care they would prefer to
receive if they develop a terminal illness or a life-
threatening injury (e.g., Alzheimer disease, cere-
brovascular accident, severe head injury). ADs
can also designate a surrogate to make deci-
sions about medical care if the patient becomes
unable to make or communicate those deci-
sions. ADs can avoid costly or specialized inter-
ventions that a patient may not desire, reduce
personal worry and futile feelings of helpless-
ness or guilt for family members, reduce overall
healthcare costs, and minimize legal concerns
for those involved. Individuals are advised to
keep a copy of the AD with their personal papers
and provide copies to their healthcare providers,
family, and proxy.
The living will and the durable power of
attorney for healthcare are types of ADs impor-
tant to the care of geriatric patients.
29
A living
will may indicate specific care or treatments the
individual consents to or refuses under certain
conditions. Care, treatments, or procedures
may include CPR in the event of cardiac or
respiratory failure, “do not resuscitate” (DNR)
designations, artificial nutrition (intravenous or
tube feedings), prolonged maintenance on a
ventilator, antibiotic therapy, blood transfusions,
spinal taps, blood cultures, initiation of dialysis,
organ donation, and autopsy. A durable power of
attorney for healthcare is a legal document that
allows an individual to appoint a proxy to make
medical or healthcare decisions in the event the
individual becomes unable to make or commu-
nicate such decisions personally. The durable
power of attorney for healthcare does not allow
the proxy to make legal or financial decisions for
the individual. In an effort to simplify the health-
related decision-making processes at the end
of life, states and organizations are combining
ADs into a single document described as an
actionable medical order that can accompany a
geriatric patient as he or she transitions between
and among levels of care. One such example is
the MOLST (Medical Orders for Life-Sustaining
Treatment) document utilized in several states.
Another popular form to document AD is the Five
Wishes™ form, which is recognized as a valid
legal document in 42 states and is available in
26 languages.
30
Problems with Advance Directives
Problems with ADs include confronting a patient
in distress with a list of possible procedures and
requiring the individual to make decisions under
duress. This can lead to unnecessary anxiety
and poor decision making on the part of the
patient. Other criticisms are that the language in
ADs can be vague or nonspecific, and an indi-
vidual’s preferences may change with circum-
stances. Individuals should be counseled to
discuss their healthcare issues with healthcare
providers, family, and caregivers and complete
ADs while they are in a state of good health. An
alternative time to complete ADs is during the
preadmission process to a healthcare institution,
prior to a planned medical procedure. A patient
executing an AD should have the ability to make
decisions for him- or herself based on the infor-
mation and choices presented, weighing the
information to determine what the decision will
mean on a personal level and then communi-
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2 - Ethical and Socioeconomic Considerations |
39
cating that decision via the AD. If a person is
unable to follow this process, he or she is said to
lack mental capacity.
A person may lack mental capacity due to
an intellectual disability, dementia, brain injury,
or mental illness. This lack of mental capacity
may be temporary. Legal capacity and the rights
that go with it remain in effect until death, unless
a court of law determines that a person can no
longer manage personal affairs in his or her own
best interest and court intervention is necessary
to protect the person. Healthcare practitioners,
even if they think the person is incapable of
making a decision, cannot overrule the person’s
expressed wishes unless a court declares the
person legally incapacitated. Guardianship is a
legal mechanism by which the court declares a
person incompetent and appoints a guardian.
The court transfers the responsibility for
managing financial affairs, living arrangements,
and medical care decisions to the guardian.
1
Surveys of elderly African Americans,
whites, and Hispanics regarding attitudes toward
completion of ADs have revealed that African
Americans and Hispanics were less likely than
white patients to have appointed a healthcare
proxy or completed an AD. The differences in AD
prevalence were related to knowledge of health-
care proxies, availability of a potential healthcare
agent, beliefs about the necessity of a formally
appointed proxy in the presence of involved
family, experience with life-prolonging tech-
nologies, age, and self-perceived health status.
These findings highlight the need for healthcare
providers to be sensitive to cultural differences
while avoiding stereotyping patients and their
beliefs around healthcare choices based on race
and ethnicity.
31
Surrogate decision makers, such
as a healthcare proxy or guardian, can benefit
emotionally from the patient having ADs in effect.
E--L D
ADs provide a foundation for making end-
of-life decisions when patients are unable to
communicate their preferences for care. Many
patients, however, are fully capable of making
and communicating end-of-life decisions as they
approach the end of their life. These patients
are faced with choices that are based on their
current experience, as opposed to the hypo-
thetical situations covered by ADs. For patients
facing these dilemmas, end-of-life decisions are
based on the expectation for their length of life
weighed against their quality of life. Length of life
decisions are based on the probability that death
is highly likely and further efforts to postpone it
are not likely to succeed. Quality-of-life decisions
address the value or worth of life if the patient
survives.
Life-Sustaining Treatments
Life-sustaining treatment is directed primarily
at preserving life despite disease, rather than
at curing the disease. The use of ventilators,
feeding tubes, dialysis, and CPR are considered
life-sustaining treatments, while chemotherapy is
a treatment often directed at curing disease. Arti-
ficial nutrition via gastric feeding tubes or intra-
venous feedings is considered a life-sustaining
treatment but is usually classified as a medical
intervention instead of routine nursing care or
comfort care.
32
After several court decisions
regarding feeding tube issues, the American
Medical Association changed its code of ethics
on comas to allow physicians to ethically with-
hold food, water, and medical treatment from
patients in irreversible comas or persistent
vegetative states with no hope of recovery, even
if death is not imminent.
33
Issues surrounding life-
sustaining treatments are commonly in litigation,
and these laws will continue to be written.
DNR Orders
When the decision is made not to revive a patient
in the event of a cardiac or pulmonary arrest, a
DNR order should be requested. It may be written
for a patient by the physician upon consultation
with the patient (if possible), the family, or the
proxy. The DNR order must be in writing and
must be signed and dated by the physician.
Patients and their families should be provided
information regarding a DNR as it relates to the
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40
| Fundamentals of Geriatric Pharmacotherapy
clinical situation, so that an informed decision
can be made. Often, the cultural and spiritual
beliefs of a patient and family guide the deci-
sion. However, the DNR document must be on
file at the patient’s current venue and cannot be
transferred from site to site. For example, a DNR
signed and filed at a nursing home is not in effect
at the hospital where the resident may be trans-
ferred for treatment.
Assisted Suicide
Assisted suicide, also known as legal-assisted
suicide or physician-assisted suicide, is the act
of ending one’s own life with the help of another
person (i.e., a physician).
1
Most states have
laws specifically prohibiting assisted suicide,
but in the recent past a few states have legal-
ized assisted suicide, which allows physicians to
prescribe a fatal dose of medication to a patient
whom the physician feels is likely to die within
6 months. Proponents of assisted suicide argue
that persons should have the right to control
their own destiny, including the right to control
how and when they die. Opponents of assisted
suicide point to the principle of nonmaleficence,
arguing that taking a life is harmful by defini-
tion. Pharmacists may be involved in ethical
dilemmas if requested to dispense prescriptions
for medications to be used in assisted suicide.
Withholding and Withdrawing
Treatments
Withholding treatment is a decision to forego
initiation of treatment or medical interventions for
a patient. When death is imminent and cannot
be prevented by available means, it is morally
permissible to withhold treatment that can yield
only a precarious prolongation of a life that may
involve a great burden for the patient or family.
1
Withdrawing (or discontinuing) treatment should
be considered when the patient is in a terminal
condition and there is a reasonable expecta-
tion of imminent death, when the patient is in
a noncognitive state with no reasonable possi-
bility of regaining cognitive function, and/or
when restoration of cardiac function will last for
a brief period. Futility of treatment, as it relates to
medical care, occurs when the healthcare prac-
titioner recognizes that the effect of treatment will
be of no benefit to the patient. Morally, the health-
care provider has a duty to inform the patient
there is little likelihood of success. The determi-
nation as to the futility of a type of medical care
is a scientific decision made by the physician.
1
Withdrawal of treatments may be selective; treat-
ments to provide comfort could be continued
while therapeutic treatments are discontinued.
Although there is ample evidence to assist
in the prescribing of safe and effective doses of
medications, there is little evidence regarding
when or how to stop or discontinue these same
medications. Holmes et al.
34
have proposed four
criteria to consider when adding or removing
medications from a geriatric patient’s medication
regimen:
1. The patient’s remaining life expectancy
(based on actuarial charts and modified by
the patient’s current health status and history)
2.
The time required to obtain benefit from the
medication (i.e., immediate for analgesics
compared to months or years for antihyper-
lipidemic agents)
3. The goals of care (a balance among preven-
tion, treatment, and palliation)
4. The treatment targets (relief of specific
symptoms that agree with goals of care)
Palliative Care
Palliative care has evolved from total care of
the terminally ill patient to active and compre-
hensive medical care aimed at symptom relief
from chronic illness. Palliative care is special-
ized medical care with a focus on identifying and
relieving pain and other symptoms of serious
illness. The goal of palliative care is to improve
quality of life for seriously ill patients at any stage
of illness, not solely terminal illness.
35
Hospice
Hospice is an interprofessional program of palli-
ative care to give supportive care to the dying
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2 - Ethical and Socioeconomic Considerations |
41
patient and his or her family in the final phase
of a terminal illness.
4
The focus of the care is on
comfort and quality of life rather than cure. The
goal is to enable the patient to be comfortable
and free of pain, so that he or she lives each
day as fully as possible, and to this end aggres-
sive methods of pain control (including high
doses of analgesics) may be used. The philos-
ophy of hospice is to provide multidisciplinary
support for the patient’s emotional, social, and
spiritual needs as well as medical symptoms
as part of treating the whole person. Hospice is
currently funded by Medicare for patients who
are deemed to have a life expectancy of less
than 6 months by their physician. A patient may
choose to enroll in a hospice program if he or
she meets this requirement. Hospice programs
are available in the home or in freestanding
facilities, nursing homes, or hospitals. Specific
laws allow for dispensing opioid analgesics with
fewer restrictions in hospice patients. Frequently,
hospice patients require medications in specially
compounded formulations to ease medication
administration. Pharmacists may be involved in
interprofessional discussions to optimize pallia-
tive therapies and to minimize treatments aimed
at prolonging life in hospice patients. Chapter
6 provides more information on palliative and
hospice care for the geriatric patient.
A, N, S
I E
Placement Issues
Aging creates losses of health, financial resources,
loved ones, and independence. Assisting geriatric
patients in compensating for losses may involve a
change in the living situation to ensure safety and
to allow for access to the necessary healthcare.
Alternatives for living situations for older patients
include high-rise independent living communities,
assisted living communities, life care retirement
communities, skilled nursing facilities, and nursing
homes/long-term care facilities. Each of these situ-
ations provides a specific type of care, and plan-
ning in anticipation of a change in functional status
can ensure the best environment for the patient’s
needs. Social issues that complicate illness in
the geriatric patient include family and caregiver
burnout, changes in family dynamics related to the
illness, family guilt, patient reluctance or refusal
to change the living situation, availability of the
appropriate type of living situation, and financing
for healthcare. As in the case of ADs, planning for
potential living situations usually allows for more
informed choices and smoother transitions.
Abuse and Neglect of the Elderly
If the social issues described above that compli-
cate geriatric care are not adequately addressed,
the geriatric patient can become vulnerable to
the environment and experience poor outcomes.
Elder abuse is classified as a type of domestic
violence and is defined as any intentional, unin-
tentional, or negligent act or series of acts that
cause harm or serious risk of harm to a vulnerable
person, typically 60 years of age or older. The
acts of abuse may be passive or active, and the
abuser may not be aware of the consequences
of his or her actions. Elder abuse may be clas-
sified as physical, emotional, financial, or sexual
and may involve neglect, abandonment, or any
combination of these.
36
Elder abuse can occur in
the home, in the community, or in healthcare insti-
tutions. Screening tools are available for use by
healthcare professionals to detect such abuse.
37
Misuse of medications, such as oversedation
or underuse of analgesic agents in a patient
with chronic pain, is a form of physical abuse.
In providing pharmaceutical care to geriatric
patients, pharmacists should evaluate medica-
tion regimens, the frequency of refill requests, as
well as the physical status of the patient to screen
for possible abuse and medication misuse. Phar-
macists, as well as all healthcare professionals,
are responsible for reporting elder abuse to local
or state authorities (i.e., Adult Protective Services,
police, or institutional administrators).
Decisions for People in Nursing
Homes
Patients are often admitted to nursing homes
because they are dependent on the services
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42
| Fundamentals of Geriatric Pharmacotherapy
of others. Most nursing home residents suffer
from some degree of physical impairment, many
suffer from cognitive impairment, and for all the
ability to provide self-care is limited. Decision
making for residents of nursing homes often
involves ethical issues,
and if residents of nursing
facilities have ADs in place or a named proxy, the
decision- making process related to healthcare
issues is less problematic.
38
The Nursing Home Resident’s Bill of Rights
was incorporated into the 1987 Nursing Home
Reform Law in order to ensure residents main-
tained the same rights as individuals living in
the community. An emphasis on the resident’s
dignity and right to self-determination pervades
the law, and facilities that receive Medicare or
Medicaid funds are obligated to meet its require-
ments. The overall goal is to prevent a decline
in health or quality of life as a consequence of
care provided by a facility. A long-term care
ombudsman program is established to aid a
resident or surrogate decision maker if these
rights are not honored. Common ethical issues
encountered in the nursing home and their
association to the Nursing Home Bill of Rights is
summarized in Table 2-3.
39
S
C
The economic and social conditions under which
people live determine their health. Diseases are
primarily determined by a network of interacting
exposures that increase or decrease the risk for
disease. The terms health disparities or healthcare
inequality refer to the differences in the quality of
health status, health outcomes, and the access
to healthcare across groups of people.
40
Health
disparities result from three primary factors:
1. the characteristics (personal, socioeco-
nomic, and environmental) of groups;
2. the barriers encountered by groups trying
to enter the healthcare delivery system; and
3. the quality of care received by groups.
Geriatric patients can experience health-
care disparities as a result of the above factors.
Specifically, geriatric patients can experience
problems accessing healthcare through:
•
lack of insurance coverage (more likely to
delay medical care and go without prescrip-
tion medications, more likely be without
health insurance or prescription insurance);
•
lack of a regular source of care (more likely
to avoid routine healthcare and receive
fragmented care through emergency rooms
or clinics);
•
lack of financial resources to pay for health-
care;
•
structural barriers (poor transportation,
inability to schedule appointments quickly
or conveniently, long wait times for care);
• healthcare financing system (likely to be
enrolled in plans with limited coverage or
with limited choices of healthcare providers);
• health literacy (problems obtaining,
processing, and understanding basic
health information; this may lead to a poor
understanding of when to seek care for
symptoms); and
• age (fixed incomes make paying for health-
care difficult, impaired mobility or lack of
transportation makes accessing healthcare
challenging, inability to use the Internet as a
source of information regarding healthcare
and wellness).
41
KEY POINT: An important
healthcare disparity for geriatric patients
is access to aordable prescriptions,
which aects medication adherence and
leads to poor healthcare outcomes.
Pharmacists have a professional obligation
to assist geriatric patients in overcoming the
socioeconomic barriers that result in healthcare
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2 - Ethical and Socioeconomic Considerations |
43
Table 2-3. Nursing Home Resident’s Bill of Rights
39
Nursing Home Residents
Have the Right to: Examples
Be fully informed Available services and the charges for each service
Facility rules and regulations, including resident rights
Address and phone number of ombudsman and state survey agency
State survey reports and the facility plan of correction
Advance plans of a change in rooms or roommates
Assistance if a sensory impairment exists
Information provided in a language you understand
Complain To present grievances to staff or others, without fear of reprisal and with
prompt efforts to resolve the grievances
To contact the ombudsman program
To file a complaint with the state survey agency and certification agency
Participate in care Receive adequate and appropriate care
Be informed of all changes in medical condition
Participate in own assessment, care planning, treatment, and discharge
Refuse medication, treatments, and physical and chemical restraints
Review own medical record
Be free from charge for services covered by Medicaid or Medicare
Privacy and confidentiality Facilitating private and unrestricted communication with any person of
their choice
During treatment and care of one’s personal needs
Regarding medical, personal, or financial affairs
Security during transfers and
discharges
Remain in facility unless removal is necessary to meet the resident’s
welfare, the health/safety of others is at risk, or for lack of payment for
services
Require 30 days’ notice and includes right of appeal
Incorporate sufficient notice for preparation
Ensure safe transfer or discharge with sufficient preparation by facility
Dignity, respect, and freedom To be treated with consideration, respect, and dignity
To be free from mental/physical abuse, corporal punishment,
involuntary seclusion, and physical/chemical restraints
To exercise self-determination
To have security of possessions
Visits By a resident’s personal physician and representatives from the state
survey agency and ombudsman programs
By relatives, friends, and others of the resident’s choosing
By organizations or individuals providing health, social, legal, or other
services
Residents have the right to refuse visitors
Make independent choices Make personal decisions, such as what to wear and how to spend free time
Ensure reasonable accommodation of one’s needs and preferences
Choose a physician and a pharmacy
Participate in community activities, both inside and outside the facility
Organize and participate in a resident council
Manage one’s own financial affairs
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44
| Fundamentals of Geriatric Pharmacotherapy
disparities by providing medication counseling
and healthcare information that is readily under-
standable by geriatric patients and assisting
these same patients in obtaining the most afford-
able medications. The newer pharmaceutical
care practice models of medication therapy
management and medication reconciliation
are valuable in ensuring that geriatric patients
receive the maximum benefit from their medica-
tions, particularly during transitions between and
among care settings.
F H
Healthcare in the United States is financed
through a combination of health insurance
programs and out-of-pocket expenses by
patients. Many changes have occurred in health
insurance plans since their introduction in the
early 1900s, and currently over 83% of health-
care expenditures are paid by private or public
insurance programs (see Table 2-4).
42
Through
the Centers for Medicare & Medicaid Services
(CMS), the Federal Government administers the
publicly financed health insurance programs of
Medicaid and Medicare. Medicaid
is the tax-
based, jointly funded, federal-state assistance
program that provides coverage of healthcare
costs to low-income people who meet eligi-
bility requirements. Eligibility for, and services
covered under, Medicaid vary among states,
and some cases require recipients to provide a
copayment for services. Medicare is the federal
health insurance program for persons 65 years
or older, the disabled, and those with end-stage
renal disease (ESRD). Medicare benefits are
paid from an account that recipients have paid
into during years of employment.
43
Prospective
payment systems for healthcare services were
instituted by the federal government in 1999 in
an effort to control costs for these programs.
In addition to the original Medicare fee-for-
service program, Medicare offers beneficiaries
the option to receive care through private insur-
ance plans. These private insurance options are
part of Medicare Part C, now called Medicare
Advantage. The most common type of Medicare
Advantage plans are health maintenance organi-
zations (HMOs). Medicare Advantage is a means
of receiving healthcare and Medicare coverage.
The beneficiary must specifically opt to receive
Medicare coverage and care through an HMO,
or other private plan insurance. Once the choice
is made, the beneficiary must generally receive
all of his or her care through the plan’s providers
in order to receive Medicare coverage. The main
premise is that through preventive care and the
use of a primary physician who acts as a gate-
keeper to specialized care, healthcare costs
can be reduced while beneficiary health can be
maintained. Problems associated with Medicare
Advantage plans are similar to those of patients
receiving care from HMOs in that beneficiaries
are limited to providers within the HMO, preap-
provals are required for specialty care, and there
is a complicated appeals process. Benefits to
Medicare Advantage plans include reduced or
absent deductibles and copays and no claim
forms to complete.
43
With the passage of the Medicare Modern-
ization Act of 2003 (MMA), Medicare Prescrip-
tion Drug Coverage or Medicare Part D became
available for Medicare beneficiaries, regardless
of income, health status, or prescription drug
usage. The Medicare Part D program provides
beneficiaries with assistance paying for prescrip-
tion drugs. Unlike coverage in Medicare Parts A
and B, Part D coverage is not provided within
the traditional Medicare program. Instead, bene-
ficiaries must affirmatively enroll in one of many
Part D plans offered by private companies. The
Medicare law establishes a standard Part D drug
benefit. Plans must offer a benefit package that
is at least as valuable as the standard benefit.
The standard benefit is defined in terms of the
benefit structure, not the particular drugs that
must be covered.
The standard benefit includes an initial
deductible amount. After meeting the deductible,
the beneficiary pays 25% of the cost of covered
Part D prescription drugs, up to an initial mone-
tary coverage limit. Once the initial coverage
limit is reached, the beneficiary is subject to
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2 - Ethical and Socioeconomic Considerations |
45
another deductible, known as the Doughnut Hole
or coverage gap, in which he or she must pay
the full costs of drugs. When total out-of-pocket
expenses on formulary drugs reach a second
monetary coverage limit (including the costs of
the deductible and coinsurance), the beneficiary
reaches the Catastrophic Coverage benefit. A
beneficiary entitled to Catastrophic Coverage
pays a modest copay for a generic or preferred
drug and a slightly larger copay for other drugs,
or a flat 5% coinsurance, whichever is greater.
This out-of-pocket amount is calculated annu-
ally. A beneficiary who reaches the out-of-pocket
threshold in 1 year has to begin to meet it again
on January 1 of the next year. Because the
deductible, initial coverage limit, and annual out-
of-pocket threshold change each year according
to the changes in expenditures for Part D drugs,
beneficiary out-of-pocket expenses may increase
annually. The Medicare law does not mandate a
set premium amount. These costs, as well as the
list of covered drugs, vary from plan to plan and
from region to region. Beneficiaries should take
time to review the various plans available to them
in light of their current and anticipated needs and
financial resources.
Table 2-4. Health Insurance Programs
Plan Financing Description Covered Services
Private
health
insurance
Private business
and patient cost
sharing
Indemnity: beneficiary
reimbursed upon claim
submission; service
benefit: healthcare
provider reimbursed
upon claim submission
Physician services, hospital services,
optional prescription benefit
Medicaid Public (the Federal
Government and
state governments)
Assistance for health
-
care; copays may be
required
Physician services and limited
prescription benefit
Medicare
Part A
Public (F
ederal
Government)
Hospital insurance (HI) Care for patients in hospitals, skilled
nursing facilities, hospice care, and
home health services
Medicare
Part B
Public (Federal
Government)
Supplemental medical
insurance (SMI)
Physician services, outpatient hospital
care, durable medical equip
-
ment, preventive services, limited
vaccines, and limited prescription
benefit
Medicare
Part C
Private insurance
companies; patient
premiums and
copays
Medicare Advantage
plans
Patients must have both Medicare
Part A and Part B; provides Part
A and Part B services and covers
additional services
Medicare
Part D
Public (Federal
Government)
Prescription drug
coverage, MTM
Outpatient prescription drugs,
limited to formularies, and annual
maximum; fee-for-service, PPOs
Medicare
supplement
Private MediGap Portion of healthcare services for
which the Medicare beneficiary has
financial responsibility
Veterans’
benefits
Federal Managed care provided
within a closed system
of veterans hospitals,
clinics, and pharmacies
Hospitalization, home health, outpa
-
tient visits, prescription medications,
and skilled nursing according to
veteran’s eligibility
https://t.me/medicina_free
46
| Fundamentals of Geriatric Pharmacotherapy
The MMA defines the drugs that are covered
under Part D and, therefore, the drugs for which
payment will be made under Part D in relation-
ship to their coverage under Medicaid and under
other parts of Medicare. A Part D drug is a drug
that is approved by the FDA, for which a prescrip-
tion is required and for which payment is required
under Medicaid. Biological products, including
insulin and insulin supplies, and smoking cessa-
tion drugs are also covered under Part D. The
MMA excludes from coverage those categories of
drugs for which Medicaid payment is optional. Of
particular significance to Medicare beneficiaries
is the exclusion of drugs for weight gain (used in
connection with treating weight loss), barbiturates
(used to treat seizures in older people), benzodi-
azepines, and over-the-counter (OTC) medica-
tions. Many of these excluded medications are
used by geriatric patients. Part D plans are not
required to pay for all covered Part D drugs.
They may establish their own formularies or list of
covered drugs for which they will make payment,
as long as the formulary and benefit structure are
not found by CMS to discourage enrollment by
certain Medicare beneficiaries. Each drug plan
must develop its own exceptions process, under
which a plan enrollee may ask the drug plan to
cover a nonformulary drug or to reduce cost
sharing for a formulary drug. Prescription drug
coverage under Part D is voluntary. A beneficiary
may purchase Part D coverage if he or she is
entitled to Part A or enrolled under Part B. The
beneficiary does not have to have both Part A
and Part B coverage to choose prescription drug
coverage. The beneficiary must enroll in a Part D
plan that serves the geographic region in which
he or she resides. The Part D benefit is premised
on the notion that individual Medicare beneficia-
ries should have a choice of private drug plans
in order to select a drug benefit that best meets
their needs.
43
An additional service available to those
enrolled in Medicare drug plans is the Medi-
cation Therapy Management (MTM) program.
MTM is a comprehensive medication review
program provided by a pharmacist or other
healthcare professional that includes a thorough
review of medications, a personal action plan
(relative to medications), and a comprehensive
list of all medications taken by a patient. Medi-
care enrollees deemed eligible for MTM review
include those with multiple chronic health condi-
tions, multiple medications, and specific medi-
cation expenses.
Medicare Part D provides coverage for
millions of American seniors who do not other-
wise have prescription insurance, yet many
seniors still lack prescription drug coverage.
Its complex structure establishes barriers with
selection of and enrollment in a prescription
drug plan (formulary) that is the best fit for the
individual geriatric patient. Also, there are limits
on annual benefit amounts with associated
out-of-pocket expenditures.
44,45
Nursing home
residents whose expenses are chiefly paid by
Medicaid or private pay receive prescription
drug coverage under Medicare Part D. Medi-
care Part D coverage in nursing homes is gener-
ally limited to plans that contract with long-term
care pharmacies in order to ensure that the drug
packaging and dosage forms needed are easily
available. In addition, immunosuppressants, oral
antineoplastics, oral antiemetics, inhalant solu-
tions, and insulin, which are covered by Medi-
care Part B, are also covered under Medicare
Part D, creating a dilemma with appropriate
billing for the long-term care pharmacy.
The passage of the Affordable Care Act
(ACA) in 2010 offered the promise of compre-
hensive health insurance reforms to include
increased access to healthcare, improved
quality of healthcare, lower healthcare costs,
and new consumer protections. One of the
features of ACA is the eventual phase-out of the
Doughnut Hole or coverage gap in the Medicare
Part D plan, expected to occur in 2020. CMS
is currently reporting cost savings on Medicare
Part D prescription drugs as a result of the imple-
mentation of ACA. The implementation of ACA in
2013 was both complex and controversial, and
frequent changes have been made to the orig-
inal legislation. The opportunities for pharmacist
involvement in collaborative practice through
https://t.me/medicina_free
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