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Medicare and Medicaid
Medicare is a federal governed program that pays for hospital and medical care for elderly and certain disabled Americans while Medicaid is a means tested health and medical services program for certain individuals and families with less resources. The populations that are served with the Medicaid are the American citizens and those people who may not necessarily be of American origin but have a legal and permanent residence in America. It also covers adults with extremely low income and their children, and people with certain disabilities.
Medicare is a predominantly federal government program and sponsored while on the other hand, Medicaid is a state governed program in collaboration with the federal government.
Medicare deals with people of age 65 and over, people of any age who may be having kidney failure and long-term kidney diseases, permanently disabled people who cannot work and it is applied for at…
Centers for Medicare and Medicaid services (2011). Medical Eligibility; Overview. Retrieved October 7, 2011 from https://www.cms.gov/medicaideligibility/
Unlike Medicare, Medicaid is not a purely federally-funded program. Every state has a Medicaid budget, which the federal government 'matches' based upon a formula, despite the fact that Medicaid is considered an entitlement, implying that enrollees are entitled to benefits regardless of where they live. Because federal funding is 'matched' that means that states that spend more on Medicaid -- usually wealthier states -- tend to receive more federal funds (Villarreal 2006). The reason for the 'matched' funding is partially due to the highly variable costs of living from state to state -- it is far more expensive to reside in New York City than Wyoming, for example -- and also to honor the principles of federalism, allowing the states to determine additional categories eligible for care. Although states must provide Medicaid for persons with income below a certain level, they do have a great deal of discretion in covering…
Luhby, Tami. (200). Medicaid busts state budgets.
CNN.com. Retrieved June 24, 2011 at http://money.cnn.com/2011/02/28/news/economy/medicaid_funding_states/index.htm
Medicare and Medicaid: What is the difference? (2011). Nolo. Retrieved June 24, 2011
Medicare and Medicaid
These two terms are government programs meant to assist specific groups of in the United States regarding health matters and are both managed by the Centers for Medicare and Medicaid Services, a division of the U.S. Department of Health and Human Services.
Medicare is a social insurance program that pays for hospital and medical care for elderly and certain disabled Americans. The program consists of hospital insurance which pays the bill of the patient including meals, supplies, testing, and a semi-private room. The hospital insurance also has home extension healthcare provision such as physical, occupational, and speech therapy as medic may deem it necessary. Medicare also covers supplementary medical insurance that makes and settles medical bills relating to physician visits, outpatient hospital visits, home health care costs and other service costs for the aged and disabled. (MediLexicon International, 2011).
On the other hand Medicaid refers to health…
SNM,(2011).Physician Certification and Licensure. Retrieved Nov 15, 2011 from http://www.snm.org/index.cfm?PageID=1089
MediLexicon International Ltd., (2011).Medical News Today. Retrieved Nov 15, 2011 from http://www.medicalnewstoday.com/info/medicare-medicaid/
Public Health Institute,(2011). Public Health. Retrieved on Nov 15, 2011 from http://www.phi.org/public_health_101/
S.E. Smith,(2011).Ambulatory care. Retrieved on Nov 15, 2011 from http://www.wisegeek.com/what-is-ambulatory-care.htm
Medicare and Medicaid
An important part of health care delivery within the state of Pennsylvania involves access to services such as Medicaid and children's insurance programs. These programs help families in need to obtain health services in order to maintain a high level of health and well-being. There are certain strengths and weaknesses exhibited by the population of Pennsylvania that may influence the consumption of insurance services.
According to the United Health Foundation (2012), Pennsylvania demonstrates strengths such as a low rate of uninsured population, high availability of physicians involved in primary care, as well as a high rate of high school graduation. In regard to weaknesses, the state of Pennsylvania has exhibited high air pollution levels, low funding for public health per capita, as well as a high prevalence of diabetes (United Health Foundation, 2012). Also, obesity as increased dramatically in the past decade, from 21.2% to 29.2% of…
CHIP: Pennsylvania's Children's Health Insurance Program (2012). Eligibility & Benefits. Retrieved 18 March 2012 from http://www.chipcoverspakids/eligibility-and-requirements.
Pennsylvania Department of Public Welfare (2012). Medical Assistance General Eligibility Requirements. Retrieved 18 March 2012 from http://www.dpw.state.pa.us/foradults/healthcaremedicalassistance/index.htm.
United Health Foundations (2012). The rankings: Pennsylvania. America's Health Rankings. Retrieved 18 March 2012 from http://www.americashealthrankings.org/PA/2011 .
The fears of the elderly were rooted in the fact that the reforms would eliminate "the tax deductibility of the 28% federal subsidy, known as the retiree drug subsidy (DS), for employers who provide creditable prescription drug coverage to Medicare beneficiaries, effective in 2013" (KFF, 2010). Thus, the 'gutting' feared by elderly Americans is the end of subsidies to private programs of elderly individuals with health coverage in addition to Medicare. The 2010 Healthcare Law also increases the Medicare payroll tax for individuals earning above $200,000 a year and establishes a new office within the Centers for Medicare & Medicaid Services (CMS) and the Federal Coordinated Health Care Office to "reduce annual market basket updates for inpatient hospital, home health, skilled nursing facility, hospice and other Medicare providers" (KFF, 2010).
Supporters of the 2010 Healthcare eform Law point out the number of Americans with no health coverage at all. The…
FAQ. (2010). The New York Times. Retrieved November 17, 2010 at http://prescriptions.blogs.nytimes.com/faq-health-care/
Focus on health reform. (2010). Kaiser Family Forum (KFF). Retrieved November 17, 2010 at http://www.kff.org/healthreform/upload/7948-02.pdf
Medicare and the Republicans. (2010, November 5) the New York Times. Retrieved November
17, 2010 at http://www.nytimes.com/2010/11/05/opinion/05fri2.html?scp=6&sq=Medicare&st=cse
Medicare and Medicaid are government-sponsored programs whose objective is to provide patients with health assistance upon meeting specific criteria. Medicare is the federal program that provides insurance for elderly patients aged 65 and over, and approximately 40 million people are enrolled in this program. Medicaid is an insurance program that is available for disadvantaged persons, including the elderly, who cannot afford health benefits because of low incomes or other factors. Both programs are subsidized by government funds and in many instances, will cover the costs of basic medical care as well as specialized testing and supplies. However, as time progresses and the elderly population increases and requires additional medical care, it is evident that Medicare and Medicaid are assuming less responsibility for healthcare costs, leaving the majority of the costs to be assumed by the patient. Furthermore, the necessity for prescription drugs is on the rise, yet pharmaceuticals are only…
Ettner, S. "Medicaid Participation Among the Eligible Elderly." Journal of Policy Analysis and Management 16.2 (1997): 237-255.
Economist. "Say Yes to Drugs." Economist 363.8279 (2002): 28-29.
Korcok, M. "U.S. MDs Respond to Pay Cuts by Turning Backs on Medicare."
Canadian Medical Association Journal 166.10 (2002): 1322.
S.A. It is worth noting that some of these parts that are left out can be very expensive at times particularly when the beneficiary has to pay the out-of-pocket premiums and deductibles as well, and these services could be inevitable like seeking medical services outside the U.S.A. Some of the services left out by the cover at times can be more expensive and life threatening that those covered hence this serves to negate the whole purpose of the CMS health care services.
In order to cover the above mentioned areas that the CMS leaves out, there is the Medicare part C which is also referred to as Medicare + Choice program which allows the beneficiary to select a private health plan provider such as the Health Maintenance Organization (HMO) who will then contract with the Medicare in order to provide all the covered health services. This is the other undoing…
Congressional Budget Office (2011). Technological Change and the Growth of Health Care
Spending. Retrieved November 10, 2011 from http://www.cbo.gov/ftpdocs/89xx/doc8947/MainText.3.1.shtml
Steven J. Lonchyna, (2011). The Evolution of Medicare and Medicaid Services. Retrieved November 10, 2011 from http://www.cwru.edu/med/epidbio/mphp439/Medicare_Medicaid.htm
Techtarget, (2011). Centers for Medicare & Medicaid Services (CMS). Retrieved November 10,
However, it presented the major problems of covering only half of the workers of the labor force and the undercutting of political support for public health insurance (erkowitz).
As social security became popular and Congress passed bills raising social security benefits in that decade, reformers were inclined to extend health insurance to social security beneficiaries, mostly elderly persons (erkowitz 2001). Most of them had stopped paying for their employer-based health insurance and had high morbidity rates. The federal government could then come in as a health provider through what came to be Medicare. The concept of limiting federally financed national health insurance for the elderly received congressional attention in 1957 (erkowitz).
In 1961, President John F. Kennedy endorsed a Medicare bill, followed by a long campaign for its passage (erkowitz 2001). The concept of national health insurance underwent another transformation or major change of sharing common grounds with…
Berkowitz, E. (2005). The past as prologue. 15 pages. Health Care Financing Review: U.S. Department of Health and Human Services
Edwards, D.J. (2005). The Medicare/Medicaid slowdown. 2 pages. Nursing Homes: Medquest Communications LLC
Sherman, M. (2004). U.S. health-care spending surges. 2 pages. Deseret News: Deseret News Publishing
Shumaker, R. (2001). Medicaid, Medicare: the differences. 4 pages. Topeka Capital Journal: Proquest Information and Learning Company
Medicaid and Medicare Value-Based Purchasing
A value chain is defined as "a linked set of value creating activities that begin with basic raw materials coming from suppliers, moving on to a series of value-added activities involved in producing and marking a product or service, and ending with distributors getting the final goods into the hands of the ultimate consumer" (Wheelen & Hunger, 2009). The process of improving raw goods along a value chain until a product is ready to bring to market includes chain segments such as uphill and downhill, and the effective supervision and analysis of its value chains is paramount to a corporation's ability to grow and thrive. The center of gravity along any value chain is defined as "the part of the chain that is most important to the company and the point where its greatest expertise and core competencies lie" (Wheelen & Hunger, 2009). Speaking of…
Burns, L.R., Degraaff, R.A., Danzon, P.M., Kimberly, J.R., Kissick, W.L. & Pauly, M.V. (2002). 'The Wharton School study of the health care value chain.' In: Burns, L.R. (Ed.), The healthcare value chain: Producers, purchasers, and providers. New York: John Wiley and Sons.
Wheelen, T., & Hunger, J.D. (2009). Internal scanning: Organizational analysis. In Strategic Management and Business Policy (12th ed.). New York, NY: Prentice Hall.
Preventing 30 Day eadmission on Medicare and Medicaid Patients
One of the most costly and common phenomenon in the modern healthcare system is the increased rates of readmission to hospital of Medicare and Medicaid patients within a short period after discharge i.e. usually within the first 30 days. These readmissions are usually caused by progression of chronic diseases among these patients as well as insufficient post-discharge care. Actually, insufficient post-discharge care is the major factor contributing to these preventable re-hospitalizations. Therefore, reducing the rates of readmissions to hospital of Medicare and Medicaid patients requires developing and implementing a new or enhanced plan for patients' follow-up after discharge. According to the findings of a recent survey, 22% of patients admitted to hospitals are either re-hospitalized or visit an emergency department within the first month after discharge (Harrison et al., 2011, p.27). This plan focuses on preventing readmission of these patients through…
Costantino, M. E., Frey, B., Hall, B., & Painter, P. (2013, November 5). The Influence of a Post
Discharge Intervention on Reducing Hospital Readmissions in a Medicare Population. Population Health Management, 16(5), 310-316. http://dx.doi.org/http://dx.doi.org.library.gcu.edu :2048/10.1089/pop.2012.0084' target='_blank' REL='NOFOLLOW'>
With four out of every ten hospital stays covered by Medicare, and almost half of hospitals’ overall revenue, Medicare cost strategies are critical for healthcare financial management (Herman, 2012). In “7 Strategies to Help Hospitals Break Even on Medicare,” Herman (2012) discusses ways hospital administrators can better manage their Medicare strategy. Hospitals do not break even on Medicare unless they implement proactive strategies for addressing potential shortfalls. Short of advocating for political reform of Medicare policies and programs, Herman (2012) claims that hospital CFOs can actually develop methods of financial management that minimize losses and ensure solvency. Herman (2012) offers seven suggestions to hospital administrators and CFOs, the most important of which is forming strategic alliances and partnerships.
Strategic partnerships are important to hospitals not just for Medicare cost structuring but for overall cost-effectiveness. Pooling resources allows all partners to benefit from their relationships, while also improving the quality of…
Herman, B. (2012). 7 Strategies to Help Hospitals Break Even on Medicare.
Kivlahan, C., Orlowski, J. M., Pearce, J., Walradt, J., Baker, M. & Kirch, D. (2016). Taking Risk: Early Results From Teaching Hospitals’ Participation in the Center for Medicare and Medicaid Innovation Bundled Payments for Care Improvement Initiative. Academic Medicine 91(7): 936-942.
The CDC has provided almost $7 million in funding to establish DPPs for research purposes, which means the number of pre-diabetes individuals helped by these programs will be very limited (CDC, 2012). While these programs will probably provide free or nearly-free diabetes preventive services to a large number of individuals, most underserved patients will not benefit from these programs.
S. 452 is worded in such a way that establishing DPPs under Medicaid will be optional for states (Sebelius, 2010). As of 2010, 43 states covered the expense of screening Medicaid patients for diabetes, but only 13 states provided reimbursement for obesity preventive services. This suggests that states are willing to pay for screening, but not preventive services like lifestyle interventions; however, if only a few states implement DPPs for Medicaid recipients, this will provide a proof-of-principle experiment in a real-world setting and establish the overall healthcare savings such programs can…
CDC (Centers for Disease Control and Prevention). (2012). National Diabetes Prevention Program. Funded Organizations. CDC.gov. Retrieved 17 Apr. 2013 from http://www.cdc.gov/diabetes/prevention/foa/index.htm .
Civic Impulse, LLC. (2013). S. 452: Medicare Diabetes Prevention Act of 2013. GovTrack.U.S.. Retrieved 17 Apr. 2013 from http://www.govtrack.us/congress/bills/113/s452 .
DPPRG (Diabetes Prevention Program Research Group). (2003). Costs associated with the primary prevention of type 2 diabetes mellitus in the diabetes prevention program. Diabetes Care, 26, 36-47.
Green, Lawrence W., Brancati, Frederick L., Albright, Ann, and PPDWG (Primary Prevention of Diabetes Working Group). (2012). Primary prevention of type 2 diabetes: Integrative public health and primary care opportunities, challenges and strategies. Family Practice, 29, i13-i23.
On April 16, 2015 an Act called the Medicare Access and CHIP Reauthorization Act (MACRA) was passed, which is a piece of history of bipartisan legislation. Eventually, on October 14, 2016 the Centers for Medicare & Medicaid Services, the department of Health and Human Services, and the regulatory agency which takes care implementing and putting into practice MACRA, gave out an ultimate rule with a comment duration putting into practice the provisions of MACRA. MACRA revokes the highly denounced Sustainable Growth Rate Formula together with its schedule for Medicare Physician Fee (MPF) cuts, substituting it with the Quality Payment Program, which is a new model that focuses on cost measurement and quality, as well as payment and reporting adjustments. Physicians and their assistants, clinical nurse specialists, nurse practitioners, and certified registered nurse anesthetics are all part of the eligible clinicians indicated in Medicare Part B and their QPP includes the…
Further, in order to be covered by Medicare, the stay at the nursing home must include care that requires skilled nursing. In other words, Medicare will not cover custodial, non-skilled or long-term care that includes activities of daily living, such as cooking, cleaning and hygiene. A stay at a skilled nursing facility under Medicare is limited to one-hundred days per ailment. Medicare will pay for the first twenty days in full. The remaining eighty days requires the patient to pay a co-payment of approximately $124.00 per day.
Under Medicare Part , Medicare will provide medical insurance to a qualified individual. This coverage includes physician and nursing services, x-rays, laboratory and diagnostic testing, influenza and pneumonia vaccinations, blood transfusions, renal dialysis, outpatient hospital treatment, some ambulance transportation, immunosuppressive drugs for organ transplant recipients, chemotherapy, hormonal treatments and other outpatient medical care treatments as administered in a physician's office. However, medication administration…
Marrelli, Tina M. (2001): Handbook of Home Health Standards and Documentation Guidelines for Reimbursement. Elsevier Health Sciences.
Matthews, Joseph L., Dorothy Matthews Berman. (2007): Social Security, Medicare and Government Pensions: Get the Most out of Your Retirement and Medical Benefits. New York: NOLO.
Vogel, Ronald J. (1999): Medicare. Anne Arbor: University of Michigan Press.
The Act creates a positive balance between government interests to save money and the interests of Medicare recipients to receive a wide range of drugs for their specific needs. The current ban on government negotiations with pharmaceutical companies serves to protect Medicate recipients by using the positives of the free market, such as the experience and purchasing power of PBMs. hile there are serious potential problems with this approach, such as the potential for fraud between pharmaceutical companies and private interests, overall the ban on government negotiations with pharmaceutical companies provides a good balance between recipient and government interests.
American Legislative Exchange Council. Prescription Drugs. 19 October 2005. http://www.alec.org/2/4/talking-points/7.html
Barry, Patricia. New Salvos in the Prescription Drug ars: Class action suits are exposing schemes that gouge consumers. AARP Bulletin, January 2005.
19 October 2005. http://www.aarp.org/bulletin/prescription/a2005-01-06-salvos.html
Dealey, Sam. Drug Dealings: Democrats had it right before. National Review Online, May…
American Legislative Exchange Council. Prescription Drugs. 19 October 2005. http://www.alec.org/2/4/talking-points/7.html
Barry, Patricia. New Salvos in the Prescription Drug Wars: Class action suits are exposing schemes that gouge consumers. AARP Bulletin, January 2005.
19 October 2005. http://www.aarp.org/bulletin/prescription/a2005-01-06-salvos.html
Dealey, Sam. Drug Dealings: Democrats had it right before. National Review Online, May 05, 2004, 9:12 A.M. 19 October 2005. http://www.nationalreview.com/comment/dealey200405050912.asp
Healthcare Law -- Ethics & Policy
Memo to ABC Hospital Board of Directors: How to develop strategies to help mitigate abuse and fraud within our organization by understanding fraud and abuse issues.
The Department of Health and Human Services has provided a great deal of good information for healthcare professionals and the public in terms of ways to avoid and/or deal with fraud and abuse. This document reflects the ways in which this hospital can be on the lookout for fraud and abuse when it comes to Medicare. This document will also explain the difference between fraud and abuse in the Medicare system.
Typically Medicare fraud means a person in this hospital -- or a doctor affiliated with this hospital contractually -- would knowingly submit false statements or somehow misrepresent what his or her services actually were, in an attempt to cheat the federal government. Also a healthcare…
Department of Health and Human Services / Centers for Medicare & Medicaid Services.
Medicare Fraud & Abuse. Retrieved March 1, 2015, from http://www.cms.gov .
Professional health care providers in direct contact with patients have been required to be licensed and credentialed demonstrating current competencies of quality and safe healthcare practice. Should similar licensing and credentialing requirements be imposed on collaborative workers in the health care industry who may not be directly serving patients (e.g., business office personnel, CEOs, CFOs, or other administrators)? Why or why not?
Collaborative health care workers should not be generally required to obtain similar licensing and credentials as their direct-patient care provider counterparts for two main reasons: redundancy and excessive costs First, requiring collaborative health care workers to obtain licensing and credentialing similar to direct patient care providers would be redundant because some collaborative health care industry executives who perform administrative tasks that do not involve direct patient care already possess professional licensing and credentials by virtue of their current occupational status and previous work experience (e.g., physicians or advanced…
Although the Medicare prescription drug program has provided access to medications for seniors at a lower cost to the government than was originally expected and has lowered the out of pocket costs for the consumers, there is talk about needing to overhaul the program. Critics contend that the government should be able to negotiate lower costs for prescription drugs than private insurances can. It is also felt that the entire program is too confusing for the elderly beneficiaries and needs to be made more understandable (Wechsler, 2008). All of these proposed changes come with Medicare still trying to uphold there objectives of providing affordable prescription drugs to seniors.
It is believed that even with these proposed changes taking place there is still a need for greater education about the program as a whole. It is hoped that with increased education that consumers will be more informed about the choices that…
Hsu, John, Fung, Vicki, Price, Mary, Huang, Jie, Brand, Richard, PharmD, Rita Hui,
Fireman, Bruce and Newhouse, Joseph. (2008). Medicare Beneficiaries' Knowledge of Part D Prescription Drug Program Benefits and Responses to Drug Costs. Journal of the American Medical Association, 299(16), 1929-1939. doi: 10.1001/jama.299.16.1929)
Lichtenberg, Frank R. And Sun, Shawn X. (2007). The Impact of Medicare Part D on Prescription Drug Use by the Elderly.
Health Affairs, 26(6), 1735-1744. doi:
Medicaid and the ACA
Discuss the issues central to the expansion of Medicaid created by the Affordable Care Act. From state policy perspective is this a good way to increase access to healthcare at a reasonable cost? Be sure to discuss the success stories you uncover as you complete your research for this question. eview the following and consider the questions below as part of your initial post.
From the State's perspective, expanding Medicaid under the ACA is a sound financial investment. However, the Supreme Court ruled that each state could decide to enter the program individually and as a consequence many states have not. These states claim that they cannot afford the program. However, a report by the Congressional Budget Office clearly shows that the Federal Government will actually be responsible for the bulk of the costs in the first decade of the program -- about 93% of the…
Angeles, J. (2012, July 25). How Health Reform's Medicaid Expansion Will Impact State Budgets. Retrieved from Center on Budget and Policy Priorities: http://www.cbpp.org/research/how-health-reforms-medicaid-expansion-will-impact-state-budgets
Klein, S., McCarthy, D., & Cohen, A. (2014). Health Share of Oregon: A Community Oriented Approach to Accountable Care for Medicaid Beneficiaries. The Commonwealth Fund, 1-12.
Semro, B. (2014, April 29). Numbers Tell the Story of ACA's Success, But They Also Show Millions are Missing Out. Retrieved from The Huffington Post: http://www.huffingtonpost.com/bob-semro/numbers-tell-the-story-of-obamacare_b_5228695.html
Medicare and Medicaid Services (CMS) announced in January that ICD- 10-CM will be implemented into the HIPAA mandated code set on Oct. 1, 2013.
Introduction to the new structure of ICD manual o Statistics
The International Classification of Diseases (ICD) is a program that is designed in order to record statistics of morbidity and mortality and for the indexing of hospital records of disease.
ICD is published by the World Health Organization (WHO).
It has always been statistically difficult to categorize diseases according to any one specific category since different professions that work with diseases have traditionally classified them according to different categories. The pathologist, for instance, is primarily interested in the natural course of the disease process, whilst the anatomist may prefer to have a classification that groups the disease according to the effected part of the body. The statistical classification of disease and injuries depends upon how the…
Healt Care Policy
Te government of te United States can influence ealt policy in many ways. Specifically, Congress as te autority to pass laws affecting te ealt care system in te country. Most recently tey debated te new ealt care law tat was passed in 2009. Tis debate was primarily between te Republicans in Congress, wo felt tat easier access to existing private insurance plans was te key to overauling te system, and te Democrats, wo preferred a government run plan to compete wit te private plans (Keefe, 2009).
Te President as te role of ceerleader and adviser, witout a direct role in passing laws. President Obama went on te campaign trail to try to rally people to is side and convince tem tat is plan to cover te uninsured, lower costs, and improve care (Stolberg, 2009). Te President can elp steer te discussion towards te direction e would like…
Antos, J. (5 Aug 2010). A mistaken prognosis for Medicare. The American. Retrieved from:
Health Policies Medicare
hen everyone in our country finally starts to reach the age of 65 years of age or older, then every person will become eligible for Medicare. It is clear that there are some elderly that are having minimum health concerns while others recurrently are dealing with medical issues for which they will have to seek out treatment by the doctor. However, research is starting to display that there are at least five top conditions that are enhancing on medical and drug spending. It is obvious that Heart disease circumstances are the number one medical issue that the those that are considered elderly are facing and that is becoming very costly to them. Most are unaware that the second one is the disease cancer and it could be internal or external for various elderly patients. Other issues such as joint ailments a lot of the times can cost…
Wenzlow, Audra T., et al. "Effects of a Discharge Planning Program on Medicaid Coverage of State Prisoners with Serious Mental Illness." Psychiatric Services 62.1 (2011): 73-8.
Sommers, Benjamin D. "Loss of Health Insurance among Non-Elderly Adults in Medicaid." Journal of General Internal Medicine 24.1 (2009): 1-7.
Verdier, James, and Allison Barrett. "How Medicaid Agencies Administer Mental Health Services: Results from a 50-State Survey." Psychiatric Services 59.10 (2008): 1203-6.
Harman, Jeffrey S., Allyson G. Hall, and Jianyi Zhang. "Changes in Health Care use and Costs After a Break in Medicaid Coverage among Persons with Depression." Psychiatric Services 58.1 (2007): 49-54.
Medicare and Medicaid Services (CMS), previously the Health Care Financing Administration (HCFA), that by the time 2011, health care expenditure will arrive at $2.8 trillion, as well as it will bill for 17% of the Gross Domestic Product. As a result, it is no revelation that white-collar offenders observe health care deception as a rewarding effort. Certainly, the General Accounting Office ("GAO") quotes that such deception accounts for up to 10% of entire health care expense (3).
As health care deception outlays taxpayers almost $100 billion a year, federal, as well as state agencies have given health care fraud tribunal a key center of attention. All through her term, Attorney General Janet Reno made impeaching health care fraud a top precedence at the Department of Justice ("DOJ"), subsequent only to brutal offenses (3).
The government focuses its pains to perceive, as well as take legal action against health care fraud…
(1) Adelaide Few & Jay Trezevant, Fighting the Battle Against Health Care Fraud & Federal Enforcement Actions, 72 FLA. B.J. 34, 34-6 (1998)
(2) Alice A. Love, Leniency Offered Health Care Providers that Admit Federal Fraud, S.D. Union Trib., Oct. 22, 1998
(3) Andy Bunds, The results of the Health Insurance Regulations on Health Care Fraud and Abuse, 72 Mont L. Rev. 63, 72 (2001)
(4) Brian A. Kaset, Sailing Without Safe Harbors: Physician Recruitment and the Law of Fraud and Abuse, 9 Healths Span. 9, 9 (1992)
Sociology Discussion Responses
Response to Post #
Your post raises some very important issues that face the entire nation as well as the individual states such as New Mexico. The largest social services programs such as Medicare and Medicaid are unsustainable for the long-term, largely because of the dramatic demographic changes in American society since their development. Today, the average longevity is almost double what it was in the early 20th century when the average life span was only 47 years of age. Likewise, the fact that the post-Word War II Baby-Boom generation is now entering retirement age means that larger than ever numbers of program beneficiaries will have to be supported by fewer working program contributors. Meanwhile, the economy is undergoing a very difficult period and unemployment and underemployment rates, even for college graduates, are at all time lows. Some of the most sensible approaches to solutions might include…
Then, when you combine this with the fact that Medicaid serves 53 million people with an annual budget of $329 billion, means that rising costs is severely affecting this program. ("Medicaid Reform," 2005) the inflexibility of this program has contributed to problem as a one size fits all approach is taken. Then, when you combine the different state programs offered through Medicaid, means that an uneven standard of inflexibility is used. An illustration of this can be seen by looking no further than the overall focus of Medicaid, where an emphasis is placed on addressing major health issues. This is problematic because like with Medicare, an approach must be taken of dealing with the patient once they are facing major health issues. Then Medicare has to engage in multiple functions to include: comprehensive acute / primary care, long-term care services (for those who qualify), a source of funding for uncompensated…
Medicaid Reform. (2005, June 15). Retrieved March 3, 2010 from National Governors Association website:
President Cuts Medicare, Medicaid to Help Reform Costs. (2009, June 15). Retrieved March 3, 2010 from California Health Line website: http://www.californiahealthline.org/articles/2009/6/15/president-outlines-cuts-to-medicare-medicaid-to-help-cover-reform-costs.aspx
Anderson, L. (2009, July 9). Research Project Finds Medicare Part D Increases Spending on Prescription Drugs.
Management of Continuum of Care Services
As the new director appointed for the Medicare and Medicaid Services (CMS), I realize the climbing costs of payments of these two programs and have met with the other members to come up with a plan of that will help enforce the strategies and guidelines in the state of North Carolina that can help us follow a budget that will assist the overall national requirements for persistent care. In doing so fellow board members have met with me to look at the Medicare Modernization Act (MMA), Administration on Aging (AoA), and other parts of the medical services to help come up with an arrangement that will help us reduce costs in our particular area that will assist the national healthcare problems that we currently face.
After looking at the problems within our own area we have decided to enforce the guidelines of the current…
Department of Health and Human Services, (n.d.). Administration on aging. Washington, DC: Retrieved from http://www.aoa.gov/aoaroot/about/Budget/DOCS/FY_2012_AoA_CJ_Feb_2011.pdf
Revering, S. (2007). Update on medicare part d. Informally published manuscript, Department of Health, Massachusetts university, Boston, Retrieved from http://docs.google.com/viewer?a=v&q=cache:vFwR3GhqkgkJ:www.mass.gov/Eeohhs2/docs/dmh/prescription_fact_sheet.ppt+medicare+modernization+act&hl=en&gl=us&pid=bl&srcid=ADGEESj-oSY8OF2PkNp5h6mbuap2CtLuhDndi5ccDFVvjGqHqGhGux-tRa0s5PrbP7CSCvtILHI8AE86mRKjnUnetKPMIgY98MGCNV_PE5PG4ZCS7robDOijjRgzUo_mPol6_0rmXtnE&sig=AHIEtbS4whuLInutr1XLxYchmbqxo8OIRw&pli=1
eimbursement Ethics and Compliance: Impact of Health Care eform on Medical Coding and Billing
"Medical billing and coding lays the foundation for any successful healthcare provider," yet its common practices are undergoing significant changes under the recent proposal for health care reform (Griffey, 2013). The nature of medical coding and billing is increasingly becoming more and more complicated. The recent healthcare reform legislation, passed in 2010, promises to complicate the situation even further. Such reforms will undoubtedly have a huge impact on medical billing and coding processes.
The reform bill was a monumental piece of legislation passed by Pres. Obama and his Democratic supporters in 2010. There are a number of stipulations which aim to help increase access to appropriate health care for millions of Americans who are currently without any coverage, helping lower the cost of premiums too much more affordable rate for most Americans but also increasing the…
Eastaugh, Ben & Sternal-Johnson, Chris (2010). What will health care reform do to medical billing? MD Alliance Billing. Web. http://mdalliancebilling.wordpress.com/2010/03/22/what-will-health-care-reform-do-to-medical-billing/
Griffey, Kimberly. (2013). Medical billing and coding and health care reform: What you need to know. Ultimate Medical Academy. Web. http://info.ultimatemedical.edu/blog/bid/276367/Medical-Billing-and-Coding-and-Health-Care-Reform-What-you-Need-to-Know
Hart, Bradley. (2012). Ethics in Medical Coding: Theory and Practice. McGraw Hill.
Jackson, Jill & Nolen, John. (2010). Health Care Reform Bill summary: A look at what's in the bill. CBS News. Web. http://www.cbsnews.com/8301-503544_162-20000846-503544/health-care-reform-bill-summary-a-look-at-whats-in-the-bill/
H's claim with an HMO plan is the need for individuals to remain within the network to receive care. Initially, Mr. H was denied coverage because he did not get a referral from his primary physician to see a specialist. The original treatment to which Mr. H's primary care physician was subjecting Mr. H was 1. not effective and 2. The physician suggested a radical amputation for his condition while the second opinion Mr. H sought suggested a much less radical procedure which would allow Mr. H to retain his mobility. It could be logically argued that had Mr. H not gone 'out of network' he would have suffered substantial medical harm. Furthermore, while the HMO cited as a reason for denial of claim a provision in the plan documents that prevents referrals outside the plan's network when the network's physicians have the capability to perform the required procedure, Mr.…
Appeals of local coverage determinations. (2010). Medicare.gov. Retrieved October 31, 2010
http://www.medicare.gov /' target='_blank' REL='NOFOLLOW'>
RATIONALE for the ELEMENTS
The rationale for the elements stated within the mission, vision and values statement is that through educating and assisting patients in signing up for and choosing their provider under the Medicare Advantage plan that the patients will be enabled to receive the best possible benefits for their individual health maintenance needs.
E. PROPOSED STRATEGIC GOALS
Strategic goals of this program includes those as follows:
1) Enrollment of all patients in the Medicare Advantage program who are eligible for this coverage.
2) Assisting all Medicare Advantage enrolled patients in utilizing this coverage to the best possible level enabling them to receive the best care possible.
F. IDENTIFICATION of CRITICAL SUCCESS FACTORS
Critical success factors are identified as being those as follows:
Adoption of the necessary technology applications to assist patients;
Efficiency and effectiveness in getting information out of patients concerning the assistance offered by the HMO; and…
Medicare Advantage: How Does it Relate? (nd) Medicare Prescription Drug Coverage. AARP. Online available at http://www.aarp.org/health/medicare/drug_coverage/a2004-03-29-medicareadvantage.html
Hoadley, Jack (2006) Medicare's New Adventure: the Part D Drug Benefit. Commission on a High Performance Health System. The Common wealth Fund Online available at http://www.cmwf.org/usr_doc/Hoadley_medicaresnewadventure_911.pdf
Rosenfeld, Sheera; Bernasek, Cathy; and Mendelson, Dan (2005) Medicare's Next Voyage: Encouraging Physicians to Adopt Health Information Technology. Health Affairs 24. No. 5, 2005. Abstract online available at http://healthaff.highwire.org/cgi/content/abstract/24/5/1138
Medicare Prescription Drug Program (2006) Chapter 5: Covering Health Issues 2006. Online available at http://www.bvsde.paho.org/bvsacd/cd57/covering/cap5.pdf
Integrity is a major issue for healthcare organizations because there are many avenues for fraud, and for people to demonstrate a lack of ethics. The problem is that the temptation is sometimes too great and despite the fact that there are laws in place to guard against these practices unethical behavior takes place anyway. The government, which supplies a lot of the money which goes for treatments through Medicare and Medicaid, has structured certain laws to make sure that the practices of healthcare organizations are ethical, but billions of dollars in fines are still doled out every year. The big drug companies complain of arcane and hard to decipher legalese, but the fact is that although they realize the issue and the penalty they continue to subvert the law. This paper looks at qui tam statutes and cases, Medicare and Medicaid admissions criteria, installing a corporate integrity program, and…
American Speech-Language-Hearing Association (ASLHA). (2010). Summary of self- referral and anti-kickback regulations. Retrieved from http://www.asha.org/practice/reimbursement/medicare/regulations_sum.htm
Hanford, J.T. (2001). Regulation of the healthcare professions. Ethics & Medicine, 17(3), 188-190.
Louthian Law Firm. (2012). Healthcare fraud qui tam whistleblower protection lawsuits.
Mattie, A. & Ben-Chitrit, R. (2009) The federal False Claims Act and qui tam actions: What every healthcare manager should know. Journal of Legal, Ethical and Regulatory Issues, 12(2), 49-65.
Health care in the United States has evolved through governmental and private answers to historical trends, starting with the first days of the United States. Often arising as responses to serious gaps in health care, these remedies traditionally build on each other and have resulted in a uniquely American health care system. The trickle of Baby Boomers into "the elderly" is now posing new challenges for both governmental and private providers, which must be met by new responses and a newly adapted health care system.
Discuss the government's role in responding to historical trends that impact the delivery of hospital care and how this has added to the expansion of hospitals in the United States.
Commencing with the very existence of our Republic, the United States government has taken a leading role in dealing with historical trends, significantly impacting delivery of hospital care and expansion of hospitals in this…
Barton, P.L. (2010). Understanding the U.S. health services system, 4th ed. Chicago, IL: Health Administration Press.
Hays Companies. (n.d.). Inpatient vs. outpatient care. Retrieved April 22, 2012 from contnt.mybenergy.com Web site: http://content.mybenergy.com/ContentTemplates/WellnessTemplate.aspx?view=user&userid=101412&link=799
Setness, P.A. (2002, June 20). The looming crisis in geriatric care: As baby boomeers age, healthcare policy fallout seems inevitable. Retrieved April 22, 2012 from ERMS.tourolib.org Web sit: https://erms.tourolib.org/url/http://proquest.umi.com/pqdweb?did=129196051&sid=4&Fmt=3&clientId=14844&RQT=309&VName=PQD
U.S. Department of Health and Human Services. (2012). Timeline of the Affordable Care Act. Retrieved April 22, 2012 from Healthcare.gov Web site: http://www.healthcare.gov/law/timeline/index.html
Balanced Budget Act of 1997
Introduction with Background
In the last several years, health care costs have been increasingly exponentially. To control the expenses associated with Medicare and Medicaid, the Balance Budget Act of 1997 was enacted. At the heart of its focus, was on reducing the total amounts of fees that are provided to health care providers, doctors and nurses. This is troubling, as these transformations will have an impact on facilities and health care professionals (who may not want to work with these kinds of patients). When this happens, there will be a decrease in choices and the overall quality of services that are provided to these individuals. This is the point that these challenges could adversely impact treatment options that are provided. (Kilgore, 2009)
Evidence of this can be seen in a study that was conducted by Kilgore (2009). She found that the act has changed consumer…
Comparative Analysis. (2012). Business Dictionary. Retrieved from: http://www.businessdictionary.com/definition/comparative-analysis.html
Qualitative Research. (2012), Wilderdom.com. Retrieved from: http://wilderdom.com/research/QualitativeVersusQuantitativeResearch.html
Kilgore, M. (2009). The Effects of the Balance Budget Act of 1997. Med Care, 47 (3), 279 -- 285.
Olsen, W. (2012). Qualitative Comparative Analysis. University of Manchester. Retrieved from: http://www.methods.manchester.ac.uk/methods/qca/
Health insurance has gone up over the past two years as a result of a nationwide increase .insurance companies have the tendency of settling only a percentage of a patient's bill. The truth of the matter is patients are not the only people who suffer due to this crisis the doctors too fall victims as mots of them opt to close down since they are underpaid by the insurance companies as well as being forced to pay the yearly premiums for malpractice .physicians are taken as the ones who are at fault for the ongoing healthcare crisis. This is true to some extent but they are not the bones to blame entirely as there are many parties involved in this issue. First of all when we look at the money involved we can say that this crisis is the fault of insurance companies since they are out there…
Sharfstein J. Fontanarosa P. & Bauchner H.(2010). Critical Issues in U.S. Health Care
Health Care on the Edge. Retrieved March 14, 2014 from http://www.commed.vcu.edu/IntroPH/Introduction/2014/criticvalissues.pdf
Lipthrott, D.(2004). Who is to blame for the healthcare crisis? Retrieved March 14, 2014 from http://www.ethicalhealthpartnerships.org/whoistoblame.html
However, this might turn competent healthcare professionals away, who were angry that they no longer could exercise discretion over their treatment, in conference with their patients. Patients might refuse to come to the hospital. And those that did would cause costs to escalate, as they stayed longer, received more extensive care, and thus exhausted their insurance benefits.
A summary presentation of a comprehensive solution that would cover all of the issues
Firstly, the board of directors should be convened to establish a policy about what the religiously founded hospital considers to be a quality life and an ethical system of evaluating critical patients, when dispensing care. Doctors, nurses, and other involved personnel must be convened to discuss various issues that continually arise and a uniform policy must be established, so that such ethical decisions are not solely the burden of patients and healthcare providers in the field.
A press release…
National Coalition on Health Care. (2004) "Health Insurance Cost." Retrieved 2 June 2005 at http://www.nchc.org/facts/cost.shtml
National Coalition on Health Care. (2004) "Health Insurance Coverage." Retrieved 2 June 2005 at http://www.nchc.org/facts/coverage.shtml
On March 23, 2010 the Patient Protection and Affordable Care Act (PPACA) was signed into law by President Barack Obama. Along with the Health Care Reconciliation Act of 2010, the PPACA became part of the overall Health Care Reform concept of 2010. The health care reform process was promoted as a way to completely transform the health care industry and ensure that all Americans received affordable health care. hile supporters praise the legislation as a revolutionary law which will benefit ordinary Americans, critics claim that the Obama Administration used the health care reform process as a means of gaining control over the entire health care system. In an attempt to compare and contrast the provisions of this new law, this essay will discuss several provisions of the new health care legislation and compare the benefits as well as the criticisms of them.
Section 5501 of the PPACA provides for…
Appleby, Julie. (2011, Jan. 10). Effort To Reward Medicare Advantage Plans Draws Criticism. Kaiser Health News. Retrieved from http://www.kaiserhealthnews.org/Stories/2011/January/10/Medpac-on-Medicare-Advantage-bonuses.aspx
"Side Effects: Obamacare Could Punish Docs for Better Quality Care." (2010, July 16). The Heritage Foundation. Retrieved from http://fixhealthcarepolicy.com/health-care-news/side-effects-obamacare-could-punish-docs-for-better-quality-care/
Gold, Jenny. (2011, Jam. 18). "Accountable Care Organizations, Explained." NPR. Retrieved from http://www.npr.org/2011/04/01/132937232/accountable-care-organizations-explained
"Health Care Reform: Annual Fee on Prescription Drug Manufacturers and Excise Tax on Medical Devise Manufacturers." (2010, Apr.). Covington & Burling LLP Retrieved from http://www.cov.com
The facts that you have provided indicate extremely troubling circumstances that could seriously jeopardize the welfare of your organization. It is well-settled law that entities contracting for the services of subsidiaries are legally responsible for legal and ethical improprieties committed by those subsidiaries irrespective of whether or not the contracting organization had any specific involvement in or knowledge of those actions. Accordingly, we would strongly advise that you take immediate action to rectify the situations described in the manner outlined in our recommendations below.
To avoid the potentially serious criminal, civil, and financial consequences arising under MWHC's respondeat superior responsibility to prevent fraud and abuse in connection with its association with subsidiaries, it is hereby recommended that MWHC immediately:
1. Instruct the subsidiary to cease and desist from offering its contracted home health agency employees compensation of any kind in connection with client durable medical equipment (DME) orders from…
Reid, T. (2009). The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care. New York: Penguin Group.
USDHHS. (2004). U.S. Department of Health and Human Services-Office of Inspector
General-Statement of Organization, Functions -- and Delegations of Authority.
Federal Register. Vol. 69, No. 127; July 2, 2004. Retrieved November 14, 2010,
egulations and Guidelines in nursing
The CMS-implemented Pay-for-Performance initiatives are designed to incentivize greater quality of care by all medical practitioners for all recipients of Medicare/Medicaid services (Fenter & Lewis, 2008). The fee-for-service model that the CMS still employs on a wide basis incentivizes a lower quality of care that leads to or includes more services, which has direct detrimental effects for patients and increases the cost burden on the Medicare and Medicaid programs and thus on the federal budget and on taxpayers (Fenter & Lewis, 2008). The Joint Commission on Accreditation of Health Organizations' Core Measures are a set of guidelines meant to modernize and standardize the processes and criteria of accreditation and ongoing measurement and quality assurance at health organizations (JCAHO, 2011). These standards are also related to care, but involve licensing and accreditation rather than payment and thus work as different incentives (JCAHO, 2011).
Fenter, T. & Lewis, S. (2008). Pay-for-Performance Initiatives. Journal of Managed Care Pharmacy 14(6): S12-5.
JCAHO. (2011). Specifications Manual for Joint Commission National Quality Core Measures. Accessed 3 April 2012. http://www.jointcommission.org/specifications_manual_joint_commission_national_quality_core_measures.aspx
Health Care Plans
Types of Health Insurance
This type of insurance is also known as a traditional or fee-for-service plan. The benefit of an indemnity plan is the flexibility; this plan allows members to choose any doctor or hospital. However, members must pay an annual deductible and then a percentage of each medical bill. Although these plans offer the greatest freedom to select any doctor, they are usually the most expensive option.
Typically, the member or the provider sends the bill to the insurance company. These plans usually have an annual deductible before the insurer starts paying. Once the deductible has been met most indemnity plans pay a percentage of what they consider the "Usual and Customary" charge for covered services. The insurer generally pays 80% of the Usual and Customary costs and the member is responsible the other 20%, known as coinsurance. If…
Rich, R.F. & Erb, C.T. (2005). The two faces of managed care regulations and policy-making. University of Illinois at Urbana-Champaign. Retrieved July 30, 2011, from http://igpa.uillinois.edu/system/files/WP114.pdf
"The Types of health insurance." (2011). Health insurance guide. Retrieved July 30, 2011, from http://www.healthinsuranceadvice.org/types.html
Risk Management Issue
Over the last several years, the issue of patient safety has been increasingly brought to the forefront. Part of the reason for this, is because a number of high profile accidents have taken place. This has increase the chances that patient will develop complications. Evidence of this can be seen by looking no further than the most commonly reported cases involving malpractices lawsuits to include: incidents involving misdiagnosis, prescription medication errors, Obstetrics and surgery. As, these different events account for a total of: 62% of all medical malpractice cases. ("CRICO Coverage," 2011) This is significant, because it shows how the underlying risks facing many health care organizations have risen exponentially. In the case of the health organization we are studying, they have taken different steps to address these kinds of issues that they are facing. To fully understand the overall scope of their strategy requires: looking at…
CRICO Coverage. (2011). Harvard University. Retrieved from: http://www.rmf.harvard.edu/
Gray, J. (2005). Real Time Patient Safety Audits. Quality Safety Health Care, 14, 284 -- 289.
Rogers, A. (2004). The Working Hours of Hospital Staff. Health Affairs, 23 (4), 202 -- 212.
Watson, R. (2008). Improving Patient Safety. Journal of Critical Care, 23 (2), 207 -- 221.
Social Work Statement of Purpose
While some people may be able to point to a distinct time or place in their lives when they knew how they wanted to make their livelihood, for others, the path to a profession cannot be mapped so precisely. My motivation to seek a Master's Social Work (MSW) degree is rooted in diverse experiences in both my personal and occupational lives.
I grew up in a family with a strong sense of community. In my extended family, some members had limited resources but they still found ways to be of help to their neighbors. When I think back to the years of my upbringing, I remember that many people in my family and community communicated their values to me, and expected me to assume a helpful stance in my life. As I grew, those expectations did too, and I learned that an aspect of my…
The problems facing Medicare recipients and the federal government almost seem to be overwhelming. There are proponents of a plan to privatize Social Security and health insurance, placing the onus on the individual to pay for his own health care through savings specifically for this. Some others would have the program go through the private HMOs who have, in the past, contained the costs of care by having primary care physicians manage a patient's care and purposely keeps the costs of care down.
As with Medicaid, the recipients of Medicare would have difficulty obtaining health care without this program. The recipients would most likely have no other health insurance. The trend being what it is, a lot of individuals retiring today are fortunate to have pensions from their companies, much less health benefits. ithout a national health insurance plan, like Medicare, those individuals would have to pay for health care…
Kay, Joseph. "Bush Plans renewed Assault on Medicaid." World Socialist Website. 8 Feb. 2005.
13 Aug. 2005. http://www.wsws.org/articles/2005/feb2005/medi-f08.shtml .
Kay, Joseph. "U.S.: States, Federal Government Prepare Massive Medicaid Cuts." World
Socialist Website. 11 May 2005. http://www.wsws.org/articles/2005/may2005/medi-m11.shtml .
"What is the role of Congress in policy making process"?
Policy is a plan to identify goal or possible course of actions with administrative or management tools to accomplish these goals. n the other hand, policy is the authoritative decision made by the U.S. executive, legislative, judicial branch of government to influence the decision of others. Government is a key player in decision-making process and congress plays important roles in decision-making . In the United States, both House of Representatives and House of Senate fulfill the congressional policy responsibilities, and congress plays important role in health policy, which includes obesity prevention measures or health insurance program. Congress is an important arm of government that makes law. Important strategy that congress uses to make policy preference is by passing a bill into law. Typically, the congress could make a decision to pass or not to the policy of the…
Oregon Department of Human Services.(2008). The impact of federal policy on Oregon's health care reform efforts: Opportunities and barriers within Medicaid and the State Children's Health Insurance Program. Medical Assistance Programs.
Waller, M. (2005).Block Grants: Flexibility vs. Stability in Social Services. Brookings Institution Policy Brief.
Zuckert, M.P. (2002). Launching Liberalism: On Lockean Political Philosophy. Lawrence: University Press of Kansas.
Strategic Management of a Healthcare Facility in St. Louis
In the late 1800's and early 1900's St. Louis was a major center for automotive and other heavy manufacturing but the industrial restructuring of the Midwest during the latter half of the century has resulted in consistent economic decline of the St. Louis region. Today however as the rest of the country faces a slowing economy this region is showing new signs of growth. [Kotkin, 2002] Due to changing socio-demographics, the demand for health care and advanced medical technologies is growing consistently with a concomitant rise in health expenditure. [Zhou 2001] Health expenditure in the U.S. has risen from 7.4% of the GNP in 1970 to 15% of the GNP in 1995.[Zhou, 2001] The Health care sector deals with not only the clinical medical services, but also include methods which finance them, for e.g. insurance, benefit schemes, Medicare and Medicaid. eforms…
1. Kotkin, J, 2002 St. Louis: On the Way to Somewhere? Rebuz Inc.
2. Author not available, 1997, Economic Report of the President. Government Printing Office, Washington, D.C. [accessed on 4/4/03]: http://www.umsl.edu/services/govdocs/erp/1997/chap3.htm
3.Author not available, 1996, Focus... Non-Elderly Missourians without Health Insurance, March 1996, Vol. 30, No. 1 [accessed on 4/4/03]: http://www.dhss.state.mo.us/MonthlyVitalStatistics/March96Vol30No1.html
4. Author not available, January 1999, Focus... Managed Care (MC+) in Medicaid Population, January 1999 Vol. 32, No. 11[accessed on 4/4/03] at http://www.dhss.state.mo.us/MonthlyVitalStatistics/Jan99Vol32No11.html
Health Care Reimbursement and Billing
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 current difficulties and complexities of current health care in the United States.
Discussion of Mrs. Zwick's coverage under Medicare Parts A, B and C
Medicare Part A (often called "hospital insurance") (U.S. Department of Health and Human Services, 2011, p. 15) assists in covering inpatient hospitalization and 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 you and/or your spouse paid Medicare taxes while employed (U.S. Department of Health and Human Services, 2011,…
Ethical implications of Mrs. Zwick's incurring costs related to her hospital-acquired condition are 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 that I work at the rehabilitation facility and neither the privilege nor the duty of diagnosis, it would be unethical for me to tell Mrs. Zwick about my suspicions. Rather, a nurse is required to maintain his/her professional boundaries (American Nurses Association, 2001, p. 6). Simultaneously, a nurse is supposed to assure "responsible disclosure of errors" to patients and act to stop bad practices and promote best practices (American Nurses Association, 2001, p. 6). Consequently, a nurse in my position faces a dilemma: lack of personal knowledge and authority vs. my concern for the patient's well-being and constant improvement of the profession. In the face of this dilemma, I would: contact the rehabilitation facility's newly-hired nurse and advise/remind him/her of the duty to report to the appropriate supervisor and responsible disclosure to Mrs. Zwick; contact Mrs. Zwick's personal physician and explain the entire situation; 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 but not limited to the urinary tract infection (American Nurses Association, 2001, p. 7). The desired outcomes would be: the rehabilitation center's absorption of Mrs. Zwick's costs related to her hospital-acquired infection through pressure exerted by its own nursing staff and Mrs. Zwick's personal physician; Mrs. Zwick's awareness of the true cause of her infection by health care providers who are directly responsible and capable.
Explain how the COBRA will allow Mr. Davis to continue his insurance coverage while he is out of work.
Due to Mr. Davis' termination from an employer of more than 20 employees, he can obtain coverage for himself, his spouse and his dependent children for up to 18 months (U.S. Department of Labor, 2012). In addition, due to his chronic cycle cell anemia, he may be entitled to an additional 11 months' extension for disability (U.S. Department of Labor, 2012). His employer is required to give a qualifying event notice to COBRA; then, COBRA sends a notice of the right to elect to continue coverage and an explanation of the steps that must be taken to continue coverage; Mr. Davis, his spouse and either or both of them in behalf of dependent children may elect for continuation of coverage
Health Care Cost and Quality
The objective of this study is to examine the relationship between health care cost and quality. This study will select one public agency and one private agency and differentiate their roles and major activities in addressing cost and quality in health care and analyze current and projected initiatives to improve quality while simultaneously controlling costs. This study will additionally conduct a synthesis of indications for staff nurses and advanced practice nurses, including evidence-based practice, relative to cost and quality.
There are many initiatives presently underway to meet the growing need of health care for a population that is greatly under-insured and many that are uninsured.
U.S. Department of Health and Human Services eport
According to the U.S. Department of Health and Human Services (2014) "Medicare is improving the way it pays for physician services. The Center for Medicare and Medicaid Innovation (Innovation Center) is exploring…
Advanced Practice Nursing: A New Age in Health Care (nd) American Nurses Association. Retrieved from: http://www.nursingworld.org/functionalmenucategories/mediaresources/mediabackgrounders/aprn-a-new-age-in-health-care.pdf
Health Care Costs (2014) Agency for Healthcare Research and Quality. Retrieved from: http://www.ahrq.gov/research/findings/factsheets/costs/health-care/index.html
A 21st Century Health Care Workforce for the Nation (2014) U.S. Department of Health and Human Services. Retrieved from: http://aspe.hhs.gov/health/reports/2014/HealthCare_Workforce/rpt_healthcareworkforce.pdf
It appears the dangers of a commercialized healthcare system have demonstrated that this beastly practice of profiting off the sick is not good for the society at many different level it contains.
Healthcare discussions of this matter do not belong in a committee that is dedicated to commercial purposes. Medicare and Medicaid were successful in the past in spite of the many governmental forces that played a role in their existence, but like all things these are old and obsolete ways of dealing with this current crisis of confusion.
A philosophical mindset, absent from this meeting, that included individual responsibility and preventative efforts to maintain health should be emphasized from leaders. Safety can never be guaranteed, neither can good health, so to offer such promises of universal coverage is over-idealistic if not criminally negligent. Like the answer to most problems, the solutions are local and come from within communities and…
Johnson administration's "Great Society" initiatives? Defend your response.
As for intentions, the Johnson administration's "Great Society" initiatives should be given an A. hen he took office, Johnson saw that the country's success following orld ar II was declining and there was a potential for the country to enter a period of serious decline, a situation which ultimately did come to pass in the 1970s and again in the present period. Programs such as Medicare and Medicaid which were created during this period have continued to benefit Americans fifty years after their initial creation. However, given that much of Johnson's attention was being given to the escalation of the Vietnam ar and Johnson's encouragement of American involvement on that front, the actual effectiveness of the "Great Society" initiatives deserves a final grade of B- or C+. He was successful in getting the Civil Rights Act passed and tried to help Americans…
Harrison, B.C. & Dye, T.R. (2008). Power and Society: an Introduction to the Social Sciences.
Maryland Health Service Cost Review Commission
Maryland is the only state that has a Board overseeing its inpatient commission. he Board is called the Maryland Health Service Cost Review Commission. It is a panel that regulates the rates for all hospital services in its state and requires all payers -- commercial, Medicaid, Medicare, self-pay -- to pay each hospital (regardless of status, history, and quality) the same fixed rate.
he he Health Services Cost Review Commission's (HSCRC's) statute was first enacted in 1971 and began setting hospital rates in 1974. At first, it pertained only to non-governmental care institutions, but, in time, the federal government granted it a waiver and the State was exempted from national Medicare and Medicaid reimbursement principles. Increasingly more and more, the HSCRC was granted power over setting rates for inpatient reimbursement, until it became the sole body that set the rates that payers pay for…
The Maryland Health Service Cost Review Commission http://www.hscrc.state.md.us/aboutHSCRC.cfm
Occupational Outlook Handbook, 2010-11 Edition. Medical Records and Health Information Technicians
If the area wage index is greater than 1, the labor share equals 69.7%. The law requires the labor share to equal 62% if the area wage index is less than 1.0.
2) the wage adjusted labor share is added to the non-labor share of the standardized amount.
3) the wage adjusted standardized amount is multiplied by a relative weight for the DG. The relative weight is specific to each of 746 DG's (for fiscal year [FY] 2009) and represents the relative average cost of a beneficiary in one DG compared to another.
4) if applicable, additional amounts will be added to the IPPS payment for hospitals engaged in teaching medical residents, hospitals that treat a disproportionate share of low income patients, and for high cost outlier cases" (Acute Inpatient Prospective Payment System, 2009).
Physician services include office visits, surgical procedures, and other diagnostic services. These services are usually performed…
Acute Inpatient Prospective Payment System. (2009). Retrieved April 2, 2009, from Centers
for Medicare and Medicade Service Web site:
http://www.cms.hhs.gov/ MLNProducts/downloads/AcutePaymtSysfctsht.pdf' target='_blank' REL='NOFOLLOW'>
Electronic Certificates of Medical Necessity: A Proposal
Medical billing can now become a relatively painless process for the personal in a medical facility through the electronic filing of certificates of medical necessity (e-CMN). Manually filling out paperwork is very time consuming, and is not very cost effective. However, the technological advancements created in the area of medical billing are very efficient. While many offices now fax the CMN's, the incorporation of e-CMN's into the medical office and billing process, decreases overhead costs, reduces paperwork, and helps substantially with the on-going battle to comply with the ever-changing Medicare requirements. While each of the previous reasons is enticing enough to consider incorporating e-CMN's into the office routine, the increase of revenue is certainly a major benefit and is the direct result of the time reduction with the filing process.
Billy Tauzin, chairman of the U.S. House Committee on Energy and Commerce, clarified…
Bachenheimer, C. (2001, Aug. 1). Something out of nothing. Home Care Magazine. Retrieved April 13, 2004 at http://homecaremag.com/ar/medical_something_nothing/index.htm .
Business Wire. (2004, Feb. 13). American association for homecare and Trac Medical Solution agree on industry wide ecmn solution. ProQuest Document: 545984641 http://gateway.proquest.com/openurl-url_ver=Z39.882004&res_dat=xri:pqd&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&genre=article&rft_txri:pqd:did=000000545984641&svc_dat=xri:pqil:fmt
McClinton, D. (2001). E-CMN's. Home Care Magazine. Retrieved April 13, 2004, at http://homecaremag.com/ar/medical_ecmns/index.htm .
Emergency Action Plan
As a strict requirement of OSHA, the clinical laboratory science department must comply to this standard that is used in describing all the appropriate actions that must be taken by the facility in order to ensure that there is proper safety in case of any accidents such as fire outbreak.
As a strict requirement of OSHA, the facility must ensure that there is a proper Fire Prevention Plan that is necessary to avert any kind of loss of either life or property.
Medical and First Aid
All the employees who work in this department must have the necessary component of both medical and first-aid providers. This is in order to ensure that any emergency situation that arises can be met with the appropriate solution.
Personal Protective Equipment
Due to the high risk of infection that is associated with the samples in the laboratory, it is…
AIUM, (2009).Standards and Guidelines for the Accreditation of Ultrasound Practices
ARDMS (2010) Introducing...MY ARDMS
While it may not be just to hold an organization liable, absolutely, for every instance of employee negligence, there is a rationale for imposing such liability in many cases. For example, many types of industries entail potential danger to others that are inherent to the industry.
Individual workers are not likely to be capable of compensating victims of their negligence, but the employer benefits and profits financially by engaging in the particular industry. Therefore, the employer should not necessarily escape liability for compensating all harm caused by their activities, regardless of fault in particular instances.
10.A nurse is responsible for making an inquiry if there is uncertainty about the accuracy of a physician's medication order in a patient's record. Explain the process a nurse should use to evaluate whether or not to make an inquiry into the accuracy of the physician's medication order.
Like other highly trained professionals, experienced nurses…
Abrams, N., Buckner, M.D. (1989) Medical Ethics: A Clinical Textbook and Reference for the Health Care Professionals. Cambridge, MA: MIT Press
Caplan, a.L., Engelhardt, H.T., McCartney, J.J. Eds. (1981) Concepts of Health and Disease: Interdisciplinary Perspectives. Reading, MA: Addison-Wesley
Starr, P. (1984) the Social Transformation of American Medicine.
New York: Basic Books
So 24 hours per day of care. With 24 hours and 8-hour shifts, 24/8 = 3 nurses are needed for each day.
If the agency works 365 days per year, and a shift is 7.5 hours, it will provide 16.43 hours of care per day, which will require 16.43 / 7.5 = 2.19 nurses per day.
4. The total workload in care hours is the weighted average of the different types of patients, so (.25)(.5) + (.25)(.8)+(.25)(1.2)+(.25)(2) = .125 + .2 + .3 + .5 = 1.125 * 5000-5625 care hours. This equates to 1.125 care hours per clinic visit.
If there were 6000 visits, divided equally among patients that require care of 0.4 hours, 0.9 hours, 1.0 hours and 2.2 hours. Under that scenario, the total workload care hours would be (.25)(.4) + (.25)(.9) + (.25)(1) + (.25)(2.2) = 1.125*6000 visits = 6750 total workload care hours, or 1.125…
Feldstein from Arizona. When the hospital was purchased by another company, they canceled the contract with Feldstein claiming that the actions that were taken were illegal. In the case, the court sided with Feldstein saying that a host of hospitals will use a variety of incentives to attract doctors. Under the Stark Law (which prohibits doctors and hospitals from making self referrals) they found that the health care facility did not violate any provision. (Stark Law 2010) However, the transaction was considered to be questionable, because of the unique arrangement that Feldstein and the hospital had about the referrals of patients. As a result, the decision would outline a number of different principals including: illegal activity arguments can be made by either party, recruiting arrangements based on referrals are in violation of federal law, hospitals need to carefully scrutinize recruiting agreements and they should develop strategies to protect themselves against…
Anti-Kickback Statute, 2011, Health Lawyers. Available from: [25 January 2011].
Federal Anti-Kick Back Laws and Safe Harbors, 1999, HHS. Available from:
The ACA does not by any means fully resolve this, but it makes strides towards addressing this critical issue of morality. The individual mandate is similar -- where the profit of one individual leads to the suffering of another, the suffering takes precedence -- the money is not as important. Not doing harm to others is the more important imperative, so the sacrifice for the greater good in this case would be the moral course of action according to Kant.
Locke's moral philosophy comprises two parts. The first is natural law, in that there are divine laws, they are obligatory and humans can understand these. The second is more hedonistic, that pleasures and pains serve to "provide morality with its normative force" (Sheridan, 2011). That these two views seem to contrast is well-established and indeed they lead to different interpretations of the key tenets of the Affordable Care Act.…
HHS.gov (2014). About the law. Department of Health and Human Services. Retrieved May 10, 2014 from http://www.hhs.gov /healthcare/rights/
Johnson, R. (2008). Kant's moral philosophy. Stanford Encyclopedia of Philosophy. Retrieved May 10, 2014 from http://plato.stanford.edu/entries/kant-moral/#GooWilMorWorDut
Sheridan, P. (2011). Locke's moral philosophy. Stanford Encyclopedia of Philosophy. Retrieved May 10, 2014 from http://plato.stanford.edu/entries/locke-moral/
0, 4.0, and 4.5 percentage points in FYs 1982, 1983, and 1984, respectively, for States whose growth exceeded certain targets, ORA-81 also reduced eligibility for welfare benefits, thus making it harder for poor families to qualify for Medicaid (Klemm, 2000). The legislation of this era began to weaken this link by specifying eligibility criteria based on income in relation to Federal poverty guidelines. In 1991, spending controls were established, provider donations were banned, and provider taxes were capped. As a result of the mandates of the previous era, the recession, and other factors, a great deal of pressure was placed on already strained State budgets, most of which were running deficits by 1991 or 1992. Increasing Medicaid caseloads (average annual growth of 12%) and mounting expenditures prompted some States to turn to alternative financing mechanisms, which relied on disproportionate share hospital (DSH) payments, combined with the use of provider donations…
Administration on Aging. (2007). Aging into the 21st Century. Retrieved March 20, 2007, at http://www.aoa.gov/prof/statistics/future_growth/aging21/summary.asp .
Bradley, D., Johnson, N., & Lay, I. (2005). The Flawed "Population Plus Inflation
Formula." Retrieved March 20, 2007, at http://www.cbpp.org/1-13-05sfp3.htm .
Coughlin, T.A., Ku, L, & Holahan, J. (1994). Medicaid Since 1980. Washington, DC:
affordable Care Act (also known as the ACA or Obamacare) on the elderly
Obamacare: Its impact upon the elderly
The impact of the Affordable Care Act (ACA) (often called 'Obamacare') upon America is often discussed by politicians as if it had a uniform impact upon all citizens. However, the ACA's effects have been relatively disparate, depending upon the nature of the population. This paper will specifically focus upon the impact of the ACA on the elderly of a variety of socio-economic categories.
One of the criticisms of the American healthcare system before the passage of the ACA was the spiraling cost of entitlement programs such as Medicare, the federally-provided health insurance program for seniors. "One good result of all this [ACA] is that the burden of Medicare for taxpayers in future years has been drastically lowered. In fact, the day Barack Obama signed the ACA into law he cut the…
ACA. http://www.hhs.gov /healthcare/rights / Accessed November 6, 2014.
FAQ: What retirees and seniors need to know about the ACA? NPR. October 11, 2013.
http://www.npr.org/2013/10/11/231101137/faq-what-retirees-and-seniors-need-to-know-about-the-affordable-care-act Accessed November 6, 2014.
Goodman, John. What seniors have to fear from Obamacare? Forbes. October 28, 2014.
Figure 1 portrays the state of Maryland, the location for the focus of this DR.
Figure 1: Map of Maryland, the State (Google Maps, 2009)
1.3 Study Structure
Organization of the Study
The following five chapters constitute the body of Chapter I: Introduction
Chapter II: Review of the Literature
Chapter III: Methods and Results
Chapter IV: Chapter V: Conclusions, Recommendations, and Implications
Chapter I: Introduction
During Chapter I, the researcher presents this study's focus, as it relates to the background of the study's focus, the area of study, the four research questions, the significance of the study, and the research methodology the researcher utilized to complete this study.
Chapter II: Review of the Literature in Chapter II, the researcher explores information accessed from researched Web sites; articles; books; newspaper excerpts; etc., relevant to considerations of the disparity in access to health care services between rural and urban residence in Maryland…
Potter, S. (2002) Doing Postgraduate Research. London: Sage.
Qualitative research: Approaches, methods, and rigour, (2008, Nov. 7). Microsoft PowerPoint Qualitative Research AdvC08 RS.PPT. Retrieved March 10, 2009 from www.unimaas.nl/bestand.asp?id=11629
Wolvovsky, Jay. (2008). Health disparities: Impact on Business and Economics Summit. Maryland's healthcare at a glance. The Heart of Community Health Baltimore Medical Syste. Retrieved March 10, 2009 at http://dhmh.maryland.gov/hd/pdf/2008/oct08/Jay_Wolvovsky.pdf
For most of U.S. history up to the time of the Community Mental Health Act of 1963, the mentally ill were generally warehoused in state and local mental institutions on a long-term basis. Most had been involuntarily committed by orders from courts or physicians, and the discharge rate was very low. Before the 1950s and 1960s, there were few effective treatments for mental illnesses like depression, anxiety disorders and schizophrenia, which were commonly considered incurable. Only with the psycho-pharmacological revolution in recent decades and new anti-depressant and anti-psychotic medications has it been possible for the severely mentally ill to be treated on an outpatient basis through community mental health centers. Of course, as the old state hospitals have emptied many of the mentally ill have ended up homeless, since they are unable to hold maintain regular employment or continue on a medication regimen without supervision. According to present-day…
Bacon. H. "Book Review: Jonathan Willows, Moving On after Childhood Sexual Abuse: Understanding the Effects and Preparing for Therapy in Clinical Child Psychology and Psychiatry. (15)1 January 2010, pp. 141-42.
Bartels, S.J., A.D. van Citters and T. Crenshaw (2010). "Older Adults" in Levin, B.L., J. Petrila and K. Hennessy Mental Health Services: A Public Health Perspective. Oxford University Presss: 261-82.
Behar, E.S. And T.D. Borkovec. (2003). "Psychotherapy Outcome Research" in I.B. Weiner et al., eds. Handbook of Psychology: Research Methods in Psychology. New York: John Wiley & Sons.
Carron, V.G. And K. Hull. (2009). "Treatment Manual for Trauma-Exposed Youth: Case Studies." Clinical Child Psychology and Psychiatry 15(1) 13 November 2009, pp. 27-38.
" (AAF, nd)
The Health Maintenance Organization further should "…negotiate with both public and private payers for adequate reimbursement or direct payment to cover the expenses of interpreter services so that they can establish services without burdening physicians…" and the private industry should be "…engaged by medical organizations, including the AAF, and patient advocacy groups to consider innovative ways to provide interpreter services to both employees and the medically underserved." (AAF, nd)
One example of the community healthcare organization is the CCO model is reported as a community cancer screening center model and is stated to be an effective mechanism for facilitating the linkage of investigators and their institutions with the clinical trials network. It is reported that the minority-based CCO was approved initially by the NCI, Division of Cancer revention Board of Scientific Counselors in January 1989. The implementation began in the fall of 1990 and the program was…
Principles for Improving Cultural Proficiency and Care to Minority and Medically-Underserved Communities (Position Paper) (2008) AAFP -- American Academy of Family Physicians http://www.aafp.org/online/en/home/policy/policies/p/princcultuproficcare.html
Volpp, Kevin G.M. (2004) The Effect of Increases in HMO Penetration and Changes in Payer Mix on In-Hospital Mortality and Treatment Patterns for Acute Myocardial Infarction" The American Journal of Managed Care. 30 June 2004. Issue 10 Number 7 Part 2. Onlineavaialble at: http://www.ajmc.com/issue/managed-care/2004/2004-07-vol10-n7Pt2/Jul04-1816p505-512
Darby, Roland B. (2008) Managed Care: Sacruificing Your Health Care for Insurance Industry Profits: Questions You must ask before joning an HMO. Online available at: http://www.rolanddarby.com/br_managedhealth.html