Medicare Coverage, COBRA, and U.S. Healthcare Challenges

Introduction

Both Mrs. Zwick and Mr. Davis face significant issues in the presented scenarios. Mrs. Zwick has multiple considerations under Medicare Parts A, B, and D, in addition to her hospital-acquired urinary tract infection. Meanwhile, Mr. Davis must address the severe time constraints and costs of COBRA in light of his job termination. These two scenarios underscore the current difficulties and complexities of healthcare in the United States.

Medicare Parts A, B, and D: Mrs. Zwick's Coverage

Medicare Part A (often called "hospital insurance") (U.S. Department of Health and Human Services, 2011, p. 15) assists in covering inpatient hospitalization, skilled nursing facilities, hospice, and home health care (U.S. Department of Health and Human Services, 2011, p. 14). There is usually no monthly premium if the beneficiary and/or their spouse paid Medicare taxes while employed (U.S. Department of Health and Human Services, 2011, p. 28). However, if a beneficiary must buy Part A, they will pay up to $451 per month (U.S. Department of Health and Human Services, 2011, p. 28). Medicare Part A will cover Mrs. Zwick's five-day inpatient hospital stay, including her semi-private room, general nursing, meals, and miscellaneous services and supplies provided by the hospital (Medicare Consumer Guide, 2012). She will pay a deductible of $1,156 and no copayment because this is within days 1–60 of her benefit period (U.S. Department of Health and Human Services, 2011, p. 34). The skilled nursing home for rehabilitation is also covered because it is deemed medically necessary following more than three days of medically necessary inpatient hospital care (U.S. Department of Health and Human Services, 2011, p. 35). Based on the projected 21-day stay, she would pay only $144.50 for the 21st day, as she pays nothing for the first 20 days (U.S. Department of Health and Human Services, 2011, p. 35). As the case facts indicate, she became ill 10 days into her stay and could not participate in rehabilitation for a full week, or 7 days. Since she stayed a total of 40 days, on the face of it she would have to pay $144.50 per day for 20 days, totaling $2,890.00 (U.S. Department of Health and Human Services, 2011, p. 35).

Medicare Part B (often called "medical insurance") (U.S. Department of Health and Human Services, 2011, p. 15) generally assists in coverage for services of doctors and other healthcare providers, outpatient care, durable medical equipment, and home health care (U.S. Department of Health and Human Services, 2011, p. 14). For this coverage, Mrs. Zwick pays a monthly premium of $99.90 (U.S. Department of Health and Human Services, 2011, p. 29). Part B will cover her doctor's bills (U.S. Department of Health and Human Services, 2011, p. 36) and the walker she received upon discharge because it qualifies as durable medical equipment. For this coverage, she must pay a deductible of $140.00, after which she will pay 20% of Medicare's approved amount for the service (U.S. Department of Health and Human Services, 2011, p. 36).

Medicare Part D (often called "prescription drug coverage") (U.S. Department of Health and Human Services, 2011, p. 14) has variable premiums and generally requires covered individuals to pay 20% of Medicare-approved drug costs (U.S. Department of Health and Human Services, 2011, p. 48). Part D will cover Mrs. Zwick's lab tests and prescription and IV drugs during hospitalization (U.S. Department of Health and Human Services, 2011, p. 14), as well as her prescription medications upon discharge from the rehabilitation facility (U.S. Department of Health and Human Services, 2011, p. 14).

Hospital-Acquired Infection: Reimbursement and Ethical Implications

As of July 31, 2008, catheter-associated urinary tract infections are included on the Centers for Medicare and Medicaid Services' list of conditions chosen for the requirement of reporting "Present On Admission" (POA) conditions (Centers for Medicare and Medicaid Services, 2012). This requirement stems from §5001(c) of the Deficit Reduction Act of 2005, in addition to the Centers for Medicare & Medicaid Services' Inpatient Prospective Payment System Fiscal Year 2009 Final Rule (Carmody, 2012). Hospitals falling within certain Medicare categories receive no reimbursement for services connected with these hospital-acquired infections and must absorb the expenses of treatment. Unfortunately, inpatient rehabilitation facilities are exempt at this time, so these laws will not apply in Mrs. Zwick's case (Centers for Medicare and Medicaid Services, 2012). Consequently, Medicare policies will officially have no effect on reimbursement for Mrs. Zwick's hospital-acquired condition.

Ethical implications for Mrs. Zwick's costs related to her hospital-acquired condition remain applicable despite the rehabilitation facility's exemption from POA/HAC Medicare laws. Having no first-hand knowledge of the cause of the urinary tract infection, no clear indication of working at the rehabilitation facility, and neither the privilege nor the duty of diagnosis, it would be unethical to share personal suspicions with Mrs. Zwick. A nurse is required to maintain professional boundaries (American Nurses Association, 2001, p. 6). At the same time, a nurse is expected to ensure "responsible disclosure of errors" to patients and to act to stop poor practices while promoting best practices (American Nurses Association, 2001, p. 6). Consequently, a nurse in this position faces a dilemma: lack of personal knowledge and authority versus concern for the patient's wellbeing and the ongoing improvement of the profession. In the face of this dilemma, the appropriate steps would be to: contact the rehabilitation facility's nurse and advise or remind them of the duty to report to the appropriate supervisor and to make responsible disclosure to Mrs. Zwick; contact Mrs. Zwick's personal physician and explain the full situation; and direct Mrs. Zwick to discuss her health issues with her personal physician, who can review, diagnose, and discuss the ramifications of her medical records, including the urinary tract infection (American Nurses Association, 2001, p. 7). The desired outcomes would be the rehabilitation center's absorption of costs related to Mrs. Zwick's hospital-acquired infection — through pressure exerted by its own nursing staff and her personal physician — and Mrs. Zwick's awareness of the true cause of her infection from the healthcare providers who are directly responsible and capable of addressing it.

Conclusion

Mrs. Zwick and Mr. Davis have widely differing medically related issues. However, they share a common thread in that they highlight the difficulties and complexities of the current healthcare system. Mrs. Zwick and her daughter were understandably perplexed by the complexity of coverage under Medicare Parts A, B, and D; simultaneously, Mrs. Zwick was unduly burdened — both financially and physically — by her hospital-acquired infection. Meanwhile, Mr. Davis must cope with his chronic illness, job termination, the time limitations and premiums of COBRA, all within a healthcare system that currently lacks the foundational determination that all people merit adequate healthcare throughout their lives. These issues reveal significant complexities and inadequacies in the current system, particularly when compared with the healthcare programs of other countries.