Reflection 11/3

This week we learned about private and public insurance. Coming into the week I did not know much about either of these topics because they did not apply much to me as a child. Now that I am quickly approaching the time in my life where I will have to chose to be on my employers insurance or stay on my guardians until I am 26, I need to be more aware of what insurance actually means to me. Dr. Shcherbakova started off her private insurance conversation by asking us why do we have insurance. At first when this question went through my head I just thought "well because we just do in order to afford healthcare costs". I am sure I am not the only one that felt like it was hard to describe exactly why we need it because, well, we have most likely always had it and never really knew we did. There is much that goes into insurance that I was not aware of.

In terms of private insurance I found it interesting that the reason we have it is due to risk. Risk is uncertainty of an event occurring. As an insurance member, in terms of health care you have to think will the event occur, how severe will it be, and how much will it cost? When it comes to health care there is not prediction as to when you are going to need to invest money into your treatment. Yes, you can put money away as a safety net but you still have no idea if that cost will cover your treatment. This is why insurance has become such a necessity When it comes to health insurance there is a variety of severities of events as well as frequencies as to when they occur. Hospitalizations can be low frequency and of high expense, physician visits can be medium frequency and expense, and prescriptions can be high frequency and low expense. All three of these encapsulate why we have health insurance on different levels and why  it is important to be prepared for any outcome. Insurance functions best to the consumer in low frequency and high severity situations. This could be anything from a house fire to an auto accident. In these times  you are not prepared to cough up the up front costs so your insurance company will do that for you. There are deductibles in some situations that you cover in order to get the process started but this is all based on your own personal insurance plan. These plans are designed for you and your financial situation as well as your tendencies as a human. Having these private insurances aid you in your day to day life so that you do not have to be constantly worried of events occurring that are out of your control; they give you a peace of mind. Understanding all of this helped me better wrap my head around how my health care journey has played out up until this point. As a child you do not understand the costs associated with routine check ups with your doctor or that random ER visit you took when you fell out of a tree. Now that I go to the doctors on my own and see the process unveil, I get how helpful insurance is in order to allow the population to have access to quality healthcare when needed. The final topic Dr. Shcherbakova brought up was PBM's. Pharmacy Benefit Manager's are middlemen that work with distributors and insurance companies to get the patient the least expensive and most effective product. Pharmacy's outsource to these companies to have their claims serviced. Pharmacy's are not the ones to blame for the price of prescriptions when the patient gets access to them, there is much  more than goes into it .PBM's work with distributors looking at cost and clinical effectiveness. They look at rebates and discounts offered by these distributors in order to get their product on the formulary. PBM's work with insurance companies to see how much of the drug will be covered and what the out of pocket will be for the patients. I never understood how much goes into this process. I thought that insurance companies had a strict regimen based on drug severity that they based their coverage on, not based on clinical and cost outcomes. After learning about PBM's I felt that their job connected much to my industry of CTMS (clinical trial management services) in the fact that they are both the middlemen and oversee-ers that ultimately make the final decision to move forward with their project. In the end the are bother trying to get drugs to market where they are safe, effective, as well as low cost. 

I thought I knew about Medicare and Medicaid before this class but I guess not. I originally thought they were the same type of insurance that was federally funded for those who applied. Medicare is for those that are 65 years of age and older and Medicaid is state funded for those with low incomes. Right now Medicare is meant to provide healthcare coverage for the elderly and has about 65 million enrollees. When it comes to this public insurance it is broken down into parts which are then added to different plans chosen for coverage. Part A is hospital coverage which means inpatient hospital care/extended, Part B is outpatient coverage such as physician services, Part C is medicare advantage which is the cost sharing option and Part D is outpatient prescriptions drugs.  The original Medicare Plan contains Part A, Part B, Part D and the Medigap. The Medicare Advantage Plan is Part C and Part D. Those who are enrolled in the program can chose which plan they would like to be a part of. When it comes to public insurance like this that is outsource funded, there is much controversy. This is because of the sheer fact that the money is coming from federal taxes and funding which draws nationally. Some think that this is an unfair advantage and some think that it is a proper way to increase the quality of life around the country. I have not had much of an opinion on this topic because I never knew much about the topic. Now that I know about the basics I can further come up with my own opinion on whether I agree with it or not.