Healthcare Coverage Influences Patient Compliance
Types of Healthcare Reimbursements Available to US Citizens

Five types of insurance are available to help support medical services.³ The type of insurance patients have determines the amount of healthcare coverage they will receive.

Medicare

Medicare is a government funded reimbursement program that covers healthcare for people over 65 years of age. The disadvantages of Medicare on intractable pain patients include:

• prescription medications are not covered unless medication is given in the physician’s office
• payments are limited for outpatient status on any service, so patients often remain in institutions and are required to undergo more expensive and sometimes more dangerous procedures

Medicare Hospice

Medicare Hospice reimburses healthcare services for patients who are at the end stage of a terminal disease, such as cancer. Medicare Hospice’s main focus is on pain relief and palliative care before death, so it does support outpatient care and prescription medications. Although Medicare Hospice provides these added services, the disadvantages of Hospice Medicare for intractable pain patients include:

• Medicare limitations exist
• hospice admissions are limited
• money is wasted on opioid medication that is left over after death because, by federal law, opioids may not be dispensed to another patient or given back to the pharmacy

Medicaid

Primary national healthcare reimbursement program, funded by federal and state governments, that aids low-income, elderly, or the disabled. The disadvantages of Medicaid for intractable pain patients include:

• governments have continually decreased funding from this program
• 25% of states that have patient-level payment restrictions, including capitations in coverage that only allow a certain number of prescription to be filled per month

The 1990 Omnibus Budget Reconciliation Act (OBRA 1990) brought about a halt to the decrease of federal and state government support of Medicaid for four years. OBRA also created a cost-savings program between the government and the pharmaceutical companies in which the pharmaceutical companies would provide a rebate on all prescription drugs in exchange for Medicaid coverage of all prescription drugs.

Private Insurance Companies

Policies vary significantly, therefore, reimbursement patterns for prescription medications and outpatient treatment are unknown.

Health Maintenance Organizations (HMOs)

HMOs are reimbursement programs, usually offered by employers that have been growing quickly since the induction of managed care. The disadvantages of HMOs for intractable pain patients include:

• 80-95% of people with HMOs have prescription medication coverage, but restrictions apply, such as generic substitutes, restrictive formularies, and pharmaceutical monitoring through utilization review programs
• riders may exist in some HMOs that may only cover prescription medications after patients pay an additional premium